No. 


PROPERTY  OF 
The  California  State  Nurses*  Association,   Inc. 

JOURNAL  LIBRARY 


Reviewed  in. 


Parifir    (~!r»a«f    Journal  r»f   Mnr«ir 


.number,  19  _ 


GIFT  OF 
Pacific  Coast 
Joupnal    of   N  r»s1noL 


JtfKMfT  UtttAlY 


THE  OPERATING  ROOM 

A  PRIMER  FOR  PUPIL  NURSES 


BY 


AMY  ARMOUR  SMITH,  R.  N. 

FORMERLY      SUPERINTENDENT      OF      NEW      KOCHELLE      HOSPITAL,      NEW 

YORK  ;      SUPERINTENDENT  OF  NURSES    AT    THE    S.  R.   SMITH  INFIRMARY, 

STATEN    ISLAND,    AND    AT     THE     WOMAN'S     HOSPITAL     OF     THE     STATE 

OF    NEW    YORK 


PHILADELPHIA  AND  LONDON 

W.  B:  SAUNDERS  COMPANY 

1916 


BIOLOoV 
LIPRARY 


GIFT  PACIFIC    ,  >& 

Qf  NURSING  TO  H/aiJ44£  DEPT 


Copyright,  1916,  by  W.  B.  Saunders  Company 


PRINTED     IN     AMERICA 


PRESS    OF 

W.     B.    SAUNDERS     COMPANY 
PHILADELPHIA 


ass 


TO 

MINE   OWN   PEOPLE 


743658 


FOREWORD 


THIS  little  book  has  been  slowly  and  anxiously  pieced 
together  not  by  one  continuous  task,  but  by  culling  an 
idea  here,  a  formula  there,  a  test  somewhere  else,  from 
the  conversations  of  numerous  good  friends  in  the  medic&l 
and  nursing  professions,  and  from  happy  memories  of 
days  in  training  under  the  kindly,  thorough  instruction  of 
Miss  A.  M.  Rykert  and  Miss  J.  MacCallum  (now  Mrs. 
Schenck,  of  Detroit),  for  the  opportunity  to  be  under 
whom  those  who  were  so  fortunate  have  been  increasingly 
proud  and  grateful  as  time  goes  by.  Yet,  withal,  this 
book  will  seem  rather  crude  in  comparison  with  the  finished 
work  of  experienced  authors.  Generously  excuse  its 
faults  on  the  ground  that  it  is  only  a  pioneer,  from  a  nurse 
to  nurses,  and  not  from  a  physician  to  nurses!  These  data 
have  been  garnered  from  journals  on  nursing,  from  physi- 
cians' libraries,  and  from  the  practical  experiences  of 
friends.  If  its  humble  appearance  proves  to  be  an  in- 
spiration to  others  more  skilled,  to  take  up  the  labor  and 
go  farther,  it  will  have  accomplished  much.  If,  again, 
any  nurse  chances  to  learn  that  she  too  can  constantly 
acquire  information  that  may  be  at  any  time,  no  matter 
how  remote,  tremendously  useful  to  her,  it  will  not  have 
been  written  in  vain. 

My  sincere  thanks  are  due  to  Dr.  T.  Mitchell  Prudden 
and  Dr.  W.  M.  Brickner  for  permission  to  quote  from 
their  valuable  works,  to  Dr.  C.  A.  Smith  and  Dr.  C.  H. 
Fulton  for  their  constant  personal  assistance,  to  Dr.  E.  M. 
Smith  and  Dr.  A.  Beck  for  contributions  on  their  special 
lines  of  work,  to  Mr.  F.  H.  Kollman  for  useful  pharma- 
ceutic  data,  and  to  the  firms  Kny-Scheerer  Corporation, 

9 


10  FOREWORD 

Foregger  Co.,  Inc.,  Lentz  &  Sons,  for  the  loan  of 
numerous  electrotypes,  and  to  J.  F.  Newman,  manufac- 
turing jeweller,  for  the  design  on  the  title-page. 

Most  especially,  however,  this  work  has  been  forwarded 
and  is  largely  due  to  the  encouragement  and  careful 
revision  given  by  Miss  B.  I.  Brazeau,  R.  N.,  and  Miss  I. 
M.  Hall,  R.  N.,  two  operating-room  nurses,  whose  abso- 
lute conscientiousness,  skill,  and  willing  spirit,  enhanced 
by  many  tenderer  graces  that  make  the  perfect  woman, 
deserve  a  far  higher  tribute  than  can  here  be  given. 

"  The  Trained  Nurse  and  Hospital  Review "  kindly 
gave  permission  to  use  the  original  articles  which  were 
expanded  for  some  of  these  chapters. 

AMY  ARMOUR  SMITH. 

NEW  ROCHELLE,  N.  Y. 
September,  1916. 


CONTENTS 


CHAPTER  I  PAGB 

OPERATING-ROOM  PUPILS 17 

Rotation  of  Service,  17— The  First  Day,  18— The  Little 
Hospital,  18 — The  Surgeon's  Duty  to  the  New  Pupil,  20— 
Good  vs.  Bad  Judgment,  21— The  Telephone,  22— Some 
Ways  of  Arranging  Work,  22 — Importance  of  Dusting,  23 — 
Honesty  in  Running  the  Sterilizers,  24 — Some  Difficulties 
which  the  Supervisor  Has  to  Solve,  24 — Sequence  of  In- 
struction, 25— Routine  Cleaning,  26— Utensils  and  Linen, 
27 — Classes  in  Anatomy  Daily,  29 — Impartiality,  29— 
Relation  Between  the  Operating  Room  and  the  Ward,  30 — 
Best  Time  to  Give  a  Pupil  this  Service,  31— Deportment,  31 
—Eight-hour  Day,  32— Scholarships,  32— Visitors,  33— 
Presence  Not  Demanded  in  Genito-urinary  Work,  33 — 
Moving  Pictures  as  Educational  Feature,  34. 

CHAPTER  II 

THE  JUNIOR  NURSE 36 

Her  Numerous  Duties,  36 — Sharpening  the  Instincts 
to  Judge  Time,  Distance,  etc.,  39 — Visitors,  42 — How  to 
Get  Ready  for  a  Second  Case,  43 — Messages  To  or  For  the 
Doctor,  45 — Engineer's  Instructions,  46 — Perspiration,  48 
—Orders  to  the  Wards,  48— Special  Beds,  48. 

CHAPTER   III 

THE  ANESTHETIC  NURSE 50 

Positions  for  Operation,  50 — Setting  Up  the  Anesthetic 
Room,  53 — Greeley  Units  for  the  Stimulation  Tray,  54 — 
Duties  to  the  Patient,  56 — Duties  to  the  Anesthetist,  57— 
Problem  of  Nurses'  Giving  Anesthetics,  58 — How  to  Fol- 
low One  Case  by  Another,  59 — Oxygen,  59 — After  the 
Operation,  61 — Special  Anesthetics,  63 — Spinal  Anesthesia, 
63— Rectal  Anesthesia,  63— The  Pulmotor,  64. 

CHAPTER   IV 

THE  SCRUBBED  NURSE 66 

Procedure  During  a  Case,  66 — Sutures,  67 — Needles,  67 
— Ligatures,  68 — Scissors,  68 — Forceps,  68 — Instruments 
in  General,  68 — Height  of  Table,  69 — Instruction  in  Con- 
ducting an  Operating  Room,  69 — General  Hints,  71. 

11 


12  CONTENTS 

CHAPTER   V 

THE  HEAD  NURSE 77 

Preparedness,  77 — Discipline,  78 — Teaching  Method,  79 
— Nursing,  80 — Common  Faults  in  Operating  Rooms,  81 — 
Legal  Phases  in  Her  Duties,  81— Routine  Work,  82— 
Ethical  Relations  with  the  Rest  of  the  House,  87— To  the 
Community,  88 — Economy  of  the  Right  Kind,  89. 

CHAPTER  VI 

THE  MAIN  OPERATING  ROOM 90 

Position  Relative  to  the  Main  Building,  90 — Lighting,  90 
— Ventilation,  90 — Temperature,  92 — Clothing  Required 
to  Work  Comfortably,  92— Corners,  93— Fumigation,  93— 
Instrument  Cases,  94 — Dark  Room,  95 — Plumbing,  96 — 
The  Table,  97— Terms  Used  in  Electric  Appliances,  97— 
Silent  Clock,  98— Special  Table  Pads,  99— Tonsil  Table,  99 
—Cautery,  99 — A  Cleanly  Way  to  Evacuate  a  Cyst,  99— 
Radium  Outfit,  101— Doors,  101— Waste  Receptacles,  101 
—Other  Rooms  of  the  Suite,  101— Elevators,  102— Fire 
Drill,  102. 

CHAPTER   VII 

THE  STERILIZING  ROOM 104 

Open-air  Shaft  to  Reduce  Humidity,  104 — Cold  Coil  on 
Both  Water  Tanks,  104— Filters,  105— Fixtures,  105— 
Height  Not  Desirable  for  Tanks,  etc.,  105 — Engineer's  In- 
structions, 106 — Perfected  Autoclave,  106 — Packing  Drums, 
106— Duty  of  Night  Nurses,  107— Tests  for  Complete  Ster- 
ilization, 107 — Distillation  of  Water,  107 — Making  Saline, 
108— Clock,  108— Other  Sterilizers,  Gloves,  Utensils,  In- 
struments, etc.,  108 — Special  Precautions  with  Apparatus, 
109 — Infections  Due  to  this  Department,  109 — Safety 
Devices,  109— Blanket  Warmer,  110— Electricity,  110— 
Flooring,  110. 

CHAPTER  VIII 

THE  WORKROOMS Ill 

Size,  Ventilation,  111— Cupboards,  111— Desk,  Counter, 
Seats,  and  Foot-rests,  111 — Rules  for  Work,  112 — Hopper 
Room,  113. 

CHAPTER   IX 

ASEPSIS .   114 

Definition,  114 — Methods  of  Carrying  Out  Asepsis,  114 
— Damp  Dressings,  115 — Mechanical  Cleanliness,  116 — 
Covers,  116— Caps,  Masks,  Glasses,  116— How  to  Stand, 
117 — Tests  by  Cultures,  118 — Tracing  the  Aseptic  Chain, 
119— Some  Errors  in  Technic,  122— How  to  Handle  Goods 
from  a  Jar,  124— Dusting,  127— Orderlies,  127— Where  the 
Anesthetist  May  Work,  127 — Contaminated  Instruments, 
128 — Breaks  in  Asepsis,  128 — How  to  Reduce  the  Activity 


CONTENTS  13 

PAGE 

of  Bacteria  Liberated  by  Any  Wound,  128— Table,  129— 
Floors,  129— Walls,  129— Shoes,  130— Health  of  Attend- 
ants, 130 — Emergency  Cases,  131 — Contagious  Cases,  131 
— Clean  Cases,  132 — Some  Problems  Confronting  the 
Supervisor,  133— Nurses  Who  Are  111,  133. 

f CHAPTER  X 

FORMULAE  AND  DIRECTIONS 136 

Thiersch's  Solution,  136— Carrel-Dakin  Antiseptic,  136 — 
lodoform  Packing,  136 — Catgut,  137 — Kangaroo  Tendon, 
138— Horsehair,  138— Silkworm-gut,  138— Silk,  138— 
Bone-wax,  138 — Aluminum  Acetate  Solution,  138 — Boric 
Acid,  139— Normal  Saline,  139— Solutions  of  Bichlorid  of 
Mercury,  140 — Formaldehyd,  141 — Nitrate  of  Silver,  141 — 
Narcotics  and  Local  Anesthetics,  142 — One  Per  Cent. 
Solutions,  142 — Rubber  Tissue,  143 — Care  of  Rubber 
Gloves,  144 — Rubber  Tubing,  146 — Catheters,  Filiforms, 
and  Bougies,  146 — Preservation  of  Specimens,  148 — Hard 
Black  Rubber  Goods,  148— Silver  Leaf,  149— Care  of  In- 
struments, 149 — Care  of  Soft-rubber  Articles,  150 — How 
to  Sterilize  Adhesive,  150 — Eye  Knives,  151 — Glass 
Syringes,  151 — Tracheotomy  Tubes,  151 — Hospital  Cold 
Cream,  152— Hospital  Hand  Lotion.  152— To  Sterilize 
Vaselin,  152. 

CHAPTER   XI 

THE  METRIC  SYSTEM.     SOME  BRIEF  NOTES 153 

Length,  153— Volume,  154— Weight,  155. 

CHAPTER   XII 

SPECIAL  DRESSINGS • 157 

Mastoid  Tips,  157— Mastoid  Dressing,  157 — Gant  Pad, 
158— Tampon  Canula,  158— Canule  a  Chemise,  158— 
Leg  Rolls,  159 — Tampons,  159 — Small  Sponges,  159— Cloth 
Retractors,  160 — Bandaging,  160 — Making  Packing,  160 — 
Eye  Pads,  160 — Aristol  Pledgets,  160— Applicators,  161— 
Tape  Stickers,  161. 

CHAPTER   XIII 

TERMS  USED  IN  SURGICAL  DIAGNOSIS 163 

A  List  of  Terms  Describing  the  Pathologic  Conditions 
that  Require  Operation  and  Their  Definitions,  165. 

CHAPTER  XIV 

LISTS  OF  INSTRUMENTS  FOR  CERTAIN  OPERATIONS,  WITH  ACCES- 
SORY ARTICLES,  AND  DETAILS  OF  ACTUAL  OPERATING- 

rooM  NURSING  CARE 185 

Head,  185— Mastoid,  186 — Cataract,  188— Submucous 
Resection  of  'the  Nasal  Septum,  188 — Frontal  Sinus 
(Radical),  189 — Radical  Operation  on  the  Ear,  190 — Jugu- 


14  CONTENTS 

PA  OB 

lar  Operation,  190 — Strabismus  Operation,  190 — Enuclea- 
tion  of  the  Eye,  191— Adenoids,  191— Tonsils,  191— 
Pharyngeal  Abscess,  192 — Tracheotomy,  192 — Brain  Ab- 
scess, 192 — Skin-grafting,  193 — Breast  Amputation,  193 — 
Resection  of  Rib  for  Empyema,  194 — Appendectomy,  196 
— Cholecystotomy,  etc.,  198 — Gastrostomy,  etc.,  200 — 
Hysterectomy,  200 — Cesarean  Section',  202 — Herniotomy, 
203— Nephrectomy,  etc.,  203— Curettage,  205— Trachelor- 
rhaphy,  206 — Perineorrhaphy,  206 — Hemorrhoidectomy 
(Ligation  Method),  206 — Operation  on  Fistula  in  Ano,  207 
— Hemorrhoidectomy  (Clamp  and  Cautery  Method),  207. 

CHAPTER  XV 

NOMENCLATURE 209 

A  List  of  the  Terms  Used  in  Naming  What  is  Done  in 
the  Operating  Room,  with  Definitions,  211. 

CHAPTER  XVI 

LINEN  OF  THE  OPERATING  ROOM 217 

How  to  Estimate  the  Amount  Needed,  217 — Patterns, 
217— White  Linen,  218— Method  of  Laundering,  218— Open 
Net  Bags,  219— Men's  T-Binders,  219— Suspensories,  219— 
Scultetus  Binders,  220 — Laparotomy  Gowns  and  Stockings, 
220 — Breast  Binder,  221— Caps,  221— Masks,  222— Vaginal 
Sheets,  223— Covers  for  Tubes  of  Packing,  225— Special 
Gown  Covers,  225 — Special  Glove  Covers,  225 — Folding 
Linen,  225— Folding  Gowns,  226— Blankets,  228— Stains, 
228 — Linen  for  Isolated  Cases,  229 — Measures  for  Suits  and 
Gowns  to  Fit  All  Figures,  229. 

CHAPTER  XVII 

BUYING  FOR  THE  OPERATING  ROOM 230 

Things  N  )t  to  Buy,  230— A  Buyer's  Duty,  230— Ameri- 
can Hospital  Bureau  of  Standards  and  Supplies,  231 — Trade 
Names,  232— Buying  a  Good  Quality  of  Stimulants,  232— 
Process  of  Obtaining  Alcohol  and  Safeguarding  It,  232 — 
How  to  Act  When  an  Important  Article  is  Needed  in  an 
Unforseen  Contingency,  233 — Expense,  233. 

CHAPTER  XVIII 

MINOR  WORK  IN  THE  OPERATING  ROOM  OR  BASED  ON  ITS 

TECHNIC 234 

Intravenous  Infusion,  234 — Hypodermoclysis,  242 — In- 
jection of  Blood-serum,  243 — Transfusion,  244 — Phlebot- 
omy, Venesection,  Blood-letting,  246 — Lumbar  Puncture, 
247 — Injection  of  Antimeningitic  Serum,  247 — Spinal  Anes- 
thesia, 248— Artificial  Respiration,  248. 


CONTENTS  15 

CHAPTER   XIX 

PREPARATIONS  BY  THE  NURSE  IN  ORTHOPEDIC  SURGERY 250 

Definition  of  Terms  of  Pathologic  Conditions,  250 — 
Description  of  Apparatus  to  Be  Made  in  Any  Operating 
Room,  252 — Bradford  Frame,  252— Buck's  Extension  for 
Fracture,  253 — Articles  for  the  Lorenz  Operation,  256 — 
Ordinary  Plaster  Cast,  257 — Putting  on  a  Cast,  258 — 
Special  Instructions,  260 — Orthopedic  Tables,  262 — Strap- 
ping for  Flat-foot,  262 — Limitations  of  General  Hospitals, 
262 — Explanation  of  Terms  Relating  to  Unusual  or  Special 
Apparatus,  263. 

CHAPTER   XX 

IMPROVISED  OPERATING   ROOM  IN  A  HUMBLE  HOME 266 

Some  Hints,  266— First  Preparations,  266— Linen,  266 — 
How  to  Sterilize,  266— Saline,  266— Operating  Table,  267 
— Trendelenburg  Position,  267 — Improvised  Kelly  Pad, 
269— Stretcher,  270— Gown,  272— Cap  and  Mask  for  the 
Nurse,  272— Cleaning  the  Room,  272. 

CHAPTER  XXI 

A  PLEA  TO  THE  SUPERINTENDENT  IN  BEHALF  OF  THE  OPER- 
ATING ROOM 274 

Its  Value  to  the  Superintendent  in  His  Administration, 
274 — Needs,  274— Sale  of  Sterile  Goods,  274— Library,  275 
— Buying  Quickly,  275 — Observation  Trips  of  Supervisor 
and  Pupils  to  Other  Institutions,  275 — Notifying  the 
Operating  Room  of  Every  Case  Coming  In,  276 — Reinforce- 
ment in  a  Rush,  276— Large  Reserve  Stock,  276— The 
Laundry,  277 — The  Superintendent's  Attitude  to  the 
Nurses  During  a  Case,  277 — Supporting  the  Supervisor  by 
Providing  Good  Servants,  278. 

CHAPTER  XXII 

THE  CHOICE  AND  APPOINTMENT  OF  AN  OPERATING  ROOM  SU- 
PERVISOR   ; 280 

Importance,  280— Relation  to  Other  Officials,  281 — De- 
sirable Qualities,  280 — Testimonials,  Degrees,  and  Demon- 
strating Ability,  282 — Method  of  Conducting  Interview, 
282 — Ratification  by  Board  of  Governors,  283 — The 
Supervisor's  Side,  284 — Registries  as  Bureaus  of  Informa- 
tion, 284— "Pull,"  285— Duties  of  the  American  Hospital 
Association,  286. 


INDEX .  289 


OPERATING  ROOM 


CHAPTER  I 

OPERATING-ROOM  PUPILS 

"A  task! — To  be  honest,  to  be  kind;  ...  to  renounce  when  that 
shall  be  necessary  and  not  be  embittered;  to  keep  a  few  friends, 
and  these  without  capitulation;  above  all,  on  the  same  grim  con- 
dition, to  keep  friends  with  himself;  here  is  a  task  for  all  that  man 
has  of  fortitude  and  delicacy." — Robert  Louis  Stevenson. 

Rotation  of  Service. — The  superintendent  or  directress 
of  nurses  must  keep  the  operating-room  supervisor  thor- 
oughly posted  about  the  pupils'  rotation  of  service,  so 
that  a  new  pupil's  arrival  in  that  department  does  not 
interfere  with  the  smoothness  of  its  workings.  Then, 
too,  illness  and  vacations  being  taken  into  consideration, 
there  must  always  be  available  one  nurse  at  least  in  small 
hospitals,  more  in  the  larger,  who  is  free  to  go.  back  to 
that  service  when  needed.  There  is  a  tension  and  im- 
portance about  this  "core  of  the  house"  that  enforces  a 
sort  of  militarism,  or  establishment  of  a  standing  army 
of  nurses  who  "have  had  operating  room."  There  is  a 
very  pleasurable  excitement  in  the  arrival  of  one  nurse 
and  the  departure  of  another,  a  large  amount  of  specu- 
lation about  where  the  latter  will  go,  and  how  the  former 
will  fit  in,  that  varies  the  monotony  of  the  daily  round. 
It  has  often  been  demonstrated  that  out  of  very  un- 
promising material  a  good  operating-room  nurse  can  be 
made,  because  of  her  sudden  flaming-up  of  enthusiasm 
for  a  new  kind  of  work  in  this  tense  atmosphere.  We 
call  it  the  "core"  of  the  house  because  it  contains  all  the 

2  17 


IS  OPERATING  BOOM 

seeds  of  the  future  success  of  the  institutions  which  under- 
take work  that  cannot  be  with  equal  facility  and  success 
conducted  at  home,  and  which  are  to  be  supervised  by 
some  of  these  same  pupils  in  the  future. 

The.  First  Day.— By  ^  careful  planning,  calculating 
on  th$  :hilp  in^&nyv'&mei'gency  of  the  pupils  who  have 
finjerje.d  .the  service,  so  as  Jo  be  perfectly  free  to  teach, 
in^^^dr^pid-of^kpltern^nt  or  demands  on  her  atten- 
tion, the  supervisor  greets  her  novice  in  the  early  morn- 
ing of  the  first  day  and  begins  at  once  to  devote  a  cer- 
tain number  of  hours  to  instructing  her  in  the  primary 
duties  she  will  have  to  perform.  It  is  impossible  to  de- 
vise arrangements  to  suit  the  operating-room  personnel 
of  all  hospitals  that  undertake  surgery,  whether  general, 
special,  private,  charitable  only,  or  emergency,  and  be- 
sides, in  a  very  large  city  where  all  these  kinds  exist  side 
by  side,  conditions  are  so  dominant  as  to  force  their  work 
into  certain  grooves.  It  is  rather  toward  the  small  hos- 
pitals in  the  suburban  counties  that  these  chapters  are 
directed,  since  they  toss  hither  and  thither  on  the  reefs 
of  crystallized  whims  of  a  few  men  who  by  their  early 
pugnacity,  doubtful  politics,  or  genuine  philanthropy 
became  the  pillars  of  the  staff  and  brought  to  its  beds 
patients  of  such  substantial  means  that  the  Board  of 
Directors  brings  a  pressure  to  bear  on  all  resident  officials 
to  humor  their  notions  somewhat.  A  generous,  open- 
handed  community,  an  upright  body  of  governors,  and 
an  ethical  Medical  Board  are  the  things  to  be  desired  for 
the  hospital's  backing,  and  it  is  in  the  hope  that  these 
are  the  goal  of  each  man's  ambition  that  the  suggestions 
herein  contained  have  been  evolved. 

The  Little  Hospital. — Many  little  operating  rooms 
have  been  successfully  conducted  by  one  graduate  nurse 
who  at  times  performed  other  duties  in  the  hospital  as 
well,  simply  calling  one  pupil  from  the  wards  during  the 
period  when  the  patient  is  under  the  anesthetic.  Some 
have  one  steady  pupil  and  one  on  call,  others  two  steady 
pupils,  and  so  on,  up  to  the  large  institutions  which  con- 


OPERATING-ROOM    PUPILS  19 

duct  several  operating  rooms  en  suite  at  once,  with  the 
large  staff  of  pupils  working  interchangeably  to  their 
mutual  advantage.  Let  not  the  little  hospital  force  be 
discouraged,  however,  because  its  gains  are  "writ  large" 
in  accuracy,  thoroughness,  and  personal  interest  in  surgeon 
and  patient,  besides  a  breadth  sometimes  that  is  derived 
from  acquaintance  with  the  methods  of  maybe  as  many 
as  twenty-five  of  the  picked  surgeons  from  a  near-by 
metropolis,  who  are  pleased  to  come  out  to  operate  on 
the  wealthy  residents  and  find  faithful,  unerring  service. 

The  little  operating  room  was  the  first  to  subscribe  to 
the  wish  now  almost  universally  voiced,  to  standardize 
operating-room  technic.  The  operating-room  supervisor, 
as  well  as  all  officials  above  her,  should  be  a  member  of 
the  American  Hospital  Association,  and  become  identified 
with  the  sessions  of  the  surgical  department.  The  Board 
of  Directors  should  pay  her  or  their  expenses  to  these 
conferences,  and  demand  a  good  report,  and  progress  in 
the  service  of  the  hospital  later.  It  is  also  incumbent 
upon  us  to  promote  more  frequent  conferences  among 
these  supervisors  within  our  own  counties.  They  are 
very  important  people.  The  occupations  of  the  in- 
habitants, inclement  climate,  facilities  for  transportation 
all  determine  largely  not  only  the  hours  at  which  opera- 
tions are  held,  but  the  nature  of  the  cases  to  be  done. 
When  they  meet  they  should  not  brag  about  how  they 
do  things,  but  should  ventilate  all  their  difficulties  and 
say,  "How  do  you  do  this  thing?  How  do  you  manage 
when  that  event  happens?  What  percentage  of  skin  in- 
fections do  you  get?"  This  requires  the  hearty  coopera- 
tion of  the  senior  officers  in  the  hospital  to  arrange  for 
substitutes  and  traveling  expenses. 

The  large  institutions  of  the  nearby  cities  should  be 
visited  to  see  modern  equipment,  new  methods,  and  often 
to  derive,  maybe,  a  great  deal  of  consolation  for  feeling 
that  in  some  respects  they  are  not  so  up  to  date  as  the 
visitor's.  But  this  moving  about  keeps  one  alert  and 
vigilant,  and  many  good  hints  are  picked  up. 


20  OPERATING   ROOM 

Few  of  the  professional  journals  accord  to  the  operating 
room  a  special  section,  and  yet,  to  the  man  on  the  street, 
to  the  nurse,  and  to  the  majority  of  the  general  prac- 
titioners who  send  cases  in  to  a  hospital,  the  operating 
room  is  "the  whole  thing." 

On  the  first  day  of  a  pupil's  term  here  the  head  nurse 
takes  her  through  what  has  been  hitherto  forbidden 
ground,  all  the  rooms  belonging  to  the  department,  so 
that  she  may  understand  the  "lay  of  the  land,"  to  find 
other  persons  quickly.  She  is  introduced  to  all  her  fellow- 
workers  in  their  respective  capacities,  scrubbed  nurse, 
anesthetic  nurse,  so  that  the  former,  who  is  very  much 
preoccupied,  need  not  be  disturbed  for  what  the  latter 
could  just  as  well  tell  her.  The  successful  supervisor 
gives  her  instructions  in  a  clear,  low,  emphatic  tone  that 
reaches  only  the  one  it  is  intended  for,  and  not  too  fast, 
at  that.  Frowns,  signs,  beckoning,  or  whispers  are  all 
very  puzzling  to  novices,  especially  because  they  come 
up  filled  with  terror,  and  are  quite  stage-struck  and  self- 
conscious  at  first. 

The  Surgeon's  Duty  to  the  New  Pupil.-  To  this  novice 
every  surgeon  or  anesthetist  has  an  obligation,  for  she  may 
some  day  be  the  brightest  star  in  his  firmament.  Instead 
of  ignoring  and  snubbing  her,  he  should  help  her  in  every 
way  within  his  power.  The  surgeon  is  so  dependent  on 
others  for  help  that  he  ought  to  be  sensible  about  building 
for  the  future.  There  will  be  times  that  a  new  pupil  has 
to  appear  in  the  main  room,  that  is,  the  most  important 
of  all  the  suite,  but  a  clever  supervisor  will  plan,  as  far  as 
any  human  being  can,  to  grade  her  work  so  that  the  novice 
is  never  confronted  with  any  condition  that  she  cannot 
completely  master.  To  arrange  so  that  the  first  thing  a 
new  pupil  is  seen  doing  she  does  well  gives  not  only  her 
but  the  surgeon  confidence.  But  he  should  be  big  enough 
of  soul  to  accept  his  share  of  the  burden  of  training  the 
pupils  of  the  school,  and  to  forget  whether  they  are 
bright  eyed  or  young,  but  to  teach  them,  impersonally, 
calmly,  and  definitely.  They  will  remember  every  word 


OPERATING-ROOM    PUPILS  21 

he  says,  and  it  is  much  more  profitable  to  say,  "I  always 
use  ten-day  chromic  for  the  perineum,"  than  to  throw  on 
the  floor  what  she  tremblingly  hands  him.  Nothing 
depleted  the  ranks  of  the  nursing  force  (i.  e.,  in  pro- 
portion to  the  increase  in  the  number  of  hospitals  and 
beds  everywhere)  like  the  oaths  and  throwing  instru- 
ments about  in  the  old-fashioned  operating  rooms. 

A  new  pupil  should  never  be  sent  to  look  for  an  instru- 
ment in  a  moment  of  panic  if  she  has  never  heard  of  it 
and  has  no  mental  image  of  it.  When  you  lose  your 
thimble,  you  will  never  find  it  if  you  think  about  pears. 
You  must  think  "thimble."  In  these  panics  the  instru- 
ment is  not  described  graphically,  the  pupil  fails  to  find 
it,  and  time  is  lost.  Be  ahead  of  the  game.  All  those 
things  must  be  laid  out  beforehand,  in  even  the  remotest 
possibility  of  being  used,  though  they  need  not  be  boiled. 
They  can  then  be  easily  pointed  out.  One  of  the  most 
meritorious  qualities  developed  in  a  careful  operating- 
room  training  is  forethought.  It  is  far  better  to  lay  out 
too  many  dressings,  or  to  open  and  thus  unsterilize  some 
special  form  of  dressing,  than  to  rush  frantically  for  some 
in  the  middle  of  a  critical  operation.  The  surgeon  has  to 
bear  all  the  responsibility  of  the  case  and  its  results, 
whether  fatal  or  happy,  before  the  visiting  physician 
who  sent  it  in,  the  relatives,  the  hospital  authorities,  and 
public  opinion.  It  is  criminal  to  leave  him  without 
good,  reliable  support  in  caring  for  the  patient.  The 
fact  that  some  surgeon  may  be  persona  non  grata  is  no 
excuse  for  sending  him  an  incompetent  pupil  as  assist- 
ant. If  all  questions  are  answered  on  the  basis,  l  'What  is 
best  for  the  patient?"  or  "How  can  we  do  the  greatest 
possible  good  to  the  greatest  possible  number?"  there  will 
be  absolutely  no  unfairness  to  any  person  connected  with 
the  institution,  whether  it  be  a  surgeon  whose  ways  are 
not  modern,  or  a  pupil  nurse  who  uses  too  many  ward 
dressings. 

Do  not  forget  what  the  hospital  is  conducted  to  ac- 
complish— to  cure  the  sick  and  to  rid  the  community  of 


22  OPERATING   ROOM 

disease,  unjust  expense,  and  unhappiness.  It  does  not 
exist  for  the  purpose  of  training  good  operating-room 
nurses.  That  occurs  if  it  does  the  other  duty  well. 

The  Telephone. — There  will  doubtless  be  free  telephone 
communication  with  the  operating-room  department  on 
account  of  the  interns'  relation  to  the  wards,  the  pres- 
ence of  visiting  doctors,  and  the  calls  of  the  surgeon's 
private  practice.  These  calls  must  be  very  clearly  taken; 
since  it  means  money  to  the  surgeon,  and  allaying  the 
anxiety  of  the  family  at  the  other  end  of  the  wire,  anxiously 
waiting.  The  supervisor,  therefore,  should  keep  a  printed 
list  of  the  names  of  the  men  who  operate  or  view  cases, 
and  teach  the  new  pupil  the  pronunciation  of  any  difficult 
foreign  names,  so  that  she,  being  the  superfluous  nurse, 
may  master  them  and  take  care  of  the  telephone.  There 
is  one  salient  feature  in  all  the  training  of  pupil  nurses, 
whether  in  a  big  metropolitan  institution  or  some  tiny 
suburban  cottage  hospital.  They  must  roam  about  and 
learn  the  names  of  all  highways  and  byways,  so  as  to  be 
familiar  with  the  vicinity  in  which  they  work,  on  ac- 
count of  calls  for  doctors,  the  addresses  of  patients,  and 
speed  in  sending  out  the  ambulance — in  brief,  the  develop- 
ment of  a  strong  business  acumen.  It  should  be  the 
duty  of  this  same  nurse  to  keep  pad  and  pointed  pencil 
for  instant  use  at  the  telephone,  this  extension  being  so 
important  that  it  should  be  of  the  desk  variety,  fixed  on 
a  table  or  desk,  and  not  on  a  wall. 

Some  Ways  of  Arranging  Work. — The  most  modern 
hospital  methods  include  in  the  first  few  months'  tuition 
of  probationers,  before  they  ever  set  foot  on  the  wards, 
the  making  of  all  hospital  dressings,  for  clinic,  ward,  or 
operating  room,  in  which  case  they  become  very  familiar 
with  the  names  of  all  forms  of  gauze  and  cotton,  i.  e.} 
wipes,  compresses,  fluffs,  sponges,  tampons,  etc.  This 
relieves  the  much  busier,  advanced  pupil  who  is  getting 
her  operating-room  training  of  a  great  deal  of  monotonous 
mechanical  work,  requiring  no  real  professional  skill 
and  acting  only  as  a  sedative  for  a  probationer's  excited 


OPERATING-KOOM    PUPILS  23 

nerves.  "Let  George  do  it"  is  a  good  motto  in  many 
respects  for  hospitals  to  apply  to  their  internal  economy. 
There  must  be  developed  accuracy,  skill,  honesty,  un- 
selfishness along  every  line,  but  it  is  the  rankest  extrava- 
gance to  make  a  second-year  pupil  sit  folding  gauze  all 
morning  and  work  then  until  midnight  in  the  operating 
room,  when  dressings  can  be  made  by  a  probationer,  a 
clean  patient,  or  an  orderly.  It  is  quite  usual  for  private 
patients,  their  special  nurses,  and  their  relatives  to  ask  for 
some  such  thing  to  do.  To  ask  a  nurse  to  do  what  any- 
one less  skilled  can  do  just  as  well,  after  she  knows  how 
to  do  it  well  and  quickly,  wastes  efficiency.  The  supply 
room  should  be  separate  from  the  rest  of  the  hospital, 
though  governed  by  the  operating  room,  so  as  to  regulate 
the  amount  of  supplies  as  estimated  from  the  operating- 
room  records,  where  clean  wounds,  discharging  wounds, 
and  goods  sold  to  physicians  are  all  entered. 

Importance  of  Dusting. — But  the  principle  of  using 
unskilled  labor  where  possible  does  not  apply  to  dusting, 
or  several  other  things  that  some  nurses  would  like  to 
evade.  Dusting  in  a  hospital  is  a  scientific  process  that 
must  be  performed  by  one  on  whom  the  hospital  can  place 
responsibility  for  the  success  of  its  work.  Orderlies  or 
maids  have  no  connection  whatever  with  the  results  in 
a  wound  further  than  their  own  healthy  condition,  but 
nurses  are  to  be  held  accountable  for  all  those  features, 
such  as  air,  light,  heat,  and  dust,  that  rank  as  accessories 
to  the  main  act.  For  the  simple  reason  that  orderlies 
and  maids  receive  no  diploma,  may  leave  at  a  second's 
notice,  and  have  no  comprehension  of  the  meaning  of 
bacteria,  dusting  must  not  be  left  to  them,  but  be  per- 
formed by  a  responsible  person.  Nurses  are  members  of 
a  class  in  society  who,  presumably,  take  pride  in  their 
work,  who  work  because  they  know  that  labor  is  neces- 
sary to  keep  well  and  sane,  who  do  things  well  because 
they  are  proud  to  excel,  and  who  want  to  satisfy  a  grow- 
ing desire  within  themselves  to  attain  more  knowledge, 
more  deftness,  and  more  approval.  The  pupil  who  covers 


24  OPERATING   ROOM 

a  great  deal  of  ground  and  takes  long  strides  and  strokes, 
occasionally  letting  things  fall  and  break,  is  a  menace, 
though  her  pyrotechnic  displays  may  impress  an  on- 
looker whose  judgment  is  shallow.  But  a  pupil  whose 
work  behind  the  scenes  is  honest  and  enduring,  who  knows 
that  the  water  in  the  sterilizers  has  boiled  long  enough, 
or  that  she  positively  has  scrubbed  every  inch  of  the 
marble  pit  with  Sapolio  and  Labarraque's  solution,  who 
remembers  and  attends  to  every  detail  of  pin,  pledget,  or 
packing  with  meticulous  care,  is  the  foundation  of  suc- 
cess in  surgery.  It  is  peculiar  and  unfortunate  that  the 
opinions  of  doctors  and  supervisors  seldom  coincide  about 
who  is  a  good  nurse.  There  is  a  sort  of  superficial  smart- 
ness and  precocity  which  take  very  well  with  surgeons 
during  their  hour  of  tense  strain,  existing  probably 
because  the  pupil  is  rested  physically,  and  has  not  fatigued 
herself  by  doing  her  whole  share  behind  the  scenes,  or 
because  she  has  naturally  more  self-possession,  or  more 
readily  places  herself  in  an  impressionable  attitude  of 
mind  to  receive  a  telepathic  intimation  of  the  surgeon's 
wish.  It  is  very  rare,  but  does  occur,  that  a  nurse  does 
her  share  of  the  rough  work  honestly  and  at  the  same  time 
shows  great  skill  and  coolness  with  instruments.  But 
passing  instruments  for  a  surgeon  has  nothing  to  do  with 
teaching  other  nurses,  or  humoring  the  relatives  of  a 
private  patient,  or  paying  one's  dressmaker  and  yet  sav- 
ing money  for  one's  old  age.  The  ethical  supervisor 
cannot  decry  the  showy,  dishonest  pupil  to  the  approving 
surgeons,  but  she  must  insist  on  thoroughness  and  com- 
pletion of  all  that  pupil's  share — no  putting  off  until  to- 
morrow what  should  be  done  today.  The  operating 
room  must  be  completely  ready  in  every  respect  at  the 
end  of  each  day. 

Some  Difficulties  which  the  Supervisor  Has  to  Solve.— 
It  makes  a  just  supervisor's  life  very  difficult  to  be  at 
close  range  with  a  pupil  whose  tricky  deceits  make  her 
feel  uneasy  about  results,  such  as  opening  the  autoclave 
too  soon,  or  making  up  a  hypodermic  dose  inaccurately, 


OPERATING-ROOM    PUPILS  25 

knowing  all  the  while  that  this  pupil  is  getting  credit  for 
cleverness  from  people  who  are  easily  fooled  by  show. 
Frank  talk  and  constant  checking  up,  combined  with  a 
nice  judgment  of  human  nature,  a  generous  allowance 
for  youthful  vanity,  and  quick  approbation  for  attempts 
to  improve  may  help  correct  these  obnoxious  conditions. 
Otherwise  they  become  a  festering  sore  in  the  heart  of 
the  remaining  pupils. 

There  is  a  special  gift  in  handing  a  surgeon  what  he 
wants  without  having  to  be  told,  but  it  is  governed  by 
certain  important  factors.  One  must  first  know  every 
inch  of  the  operating-room  suite.  This  is  gained  by 
daily  dusting,  putting  supplies  away,  and  taking  inven- 
tory. Second,  one  must  have  in  mind  an  accurate,  ana- 
tomic picture  of  the  operation  to  be  performed.  This 
must  be  taught  before  each  kind  of  case  to  the  pupils 
who  will  take  part.  Then,  third,  one  must  have  all  the 
goods  required  generously  supplied  in  a  systematic  way 
on  the  sterile  tables.  Fourth,  the  workings  of  every  screw, 
lever,  and  button  on  instruments,  cautery,  or  lights  must 
be  thoroughly  known  beforehand,  learned  in  quiet  lesson 
hours  and  practised  to  get  speed,  without  an  audience. 
To  control  the  welfare  of  pupils  or  patients  by  these 
methods  gives  the  shy  nurse  an  equal  chance,  and  elevates 
the  operating-room  supervisor's  position  to  a  lofty  degree. 

Sequence  of  Instruction. — After  the  pupil  has  been 
introduced  to  every  hole  and  corner  in  her  new  scene  of 
labor,  she  should  be  quizzed  to  find  whether  she  took  in 
what  she  saw,  so  as  to  form  the  habit  of  observation: 

(1)  What  rooms  adjoin  the  operating  room? 

(2)  Where  is  the  oxygen  kept? 

(3)  Where  is  the  normal  saline? 

(4)  W^ho  is  anesthetic  nurse? 

(5)  Which  is  the  hot-water  sterilizer? 

(6)  How  many  stands  are  in  the  scrub-up  room? 

In  making  these  rounds  the  head  nurse  should  frankly 
point  out  existing  difficulties — to  watch  for  the  backward 
swing  of  a  certain  door,  to  keep  screens  in  all  windows, 


26  OPERATING  ROOM 

to  swat  flies,  to  keep  steam  out  of  the  main  room  or  to 
reduce  noise — always  showing  what  would  be  an  ideal 
condition  to  foster  in  these  minds  the  ideas  that  will 
result  in  finer  construction  and  equipment  in  future 
hospitals.  Couple  work  with  hopeful  imagination. 

Routine  Cleaning. — In  teaching  the  pupil  to  dust  the 
method  should  coincide  reasonably  with  that  employed  in 
the  wards — soap  and  water  and  two  dusters,  with  Bon  Ami 
smeared  on  glass  to  dry.  The  supervisor  demonstrates 
the  direction  of  movement,  beginning  in  corners  and  com- 
ing to  the  center;  the  system  of  going  around  a  table  or 
chair  rung  after  rung  in  orderly  rotation,  not  hither  and 
yon,  so  that,  if  called  away,  one  knows  where  to  start 
again,  since  in  this  department  everything  must  be 
covered  completely,  not  just  the  seemingly  dirty  spots. 

Dusters  of  various  kinds  are  needed,  stout,  soft-made 
cheese-cloth  dusters  for  rubbing  soap  or  Bon  Ami  on, 
brushes  for  Sapolio,  and  thick,  dry,  lintless  cotton  cloths 
for  drying  and  polishing.  In  the  hopper  room  are  kept 
all  articles  for  damp  work;  therefore  this  room  must  be 
well  sunned  and  aired.  Each  nurse  should  dust  her 
own  section  of  the  operating-room  suite,  so  that  it  is  all 
finished  early.  The  new  nurse  is  not  a  drudge  or  a  Cin- 
derella. If  she  spends  all  morning  cleaning  while  nobody 
else  does  any,  the  place  is  not  in  order  on  time,  and  she 
is  not  learning  any  the  ways  in  which  she  should  become 
instantly  useful,  a  fleet-footed  messenger.  Mops,  brooms, 
and  brushes  belonging  to  each  worker  are  kept  separate, 
so  as  to  be  easily  checked  up  or  found.  It  is  wrong  to 
ask  an  orderly  to  do  any  scrubbing  higher  than  the  floor 
or  lower  than  the  chandelier.  In  any  case,  he  should  be 
well  supervised. 

In  whatever  section  the  pupil  nurse  is  placed,  whether 
new  (and  "dirty"),  anesthetic,  or  scrubbed,  she  should 
constantly  observe  what  the  one  next  highest  has  to  do. 
The  average  hospital  has  three  pupils  on  this  service  for 
from  six  weeks  to  three  months  each,  giving  them  from 
one-half  to  a  whole  month  in  each  of  these  sections  above 


OPERATING-ROOM    PUPILS  27 

named.  Three  or  four  days  are  enough  to  become  sub- 
consciously familiar  with  routine  duties,  so  as  to  cast  a 
free  eye  on  the  work  of  one's  immediate  senior,  because 
emergencies  of  every  kind  will  be  conducted  well  by  this 
acquisition  of  knowledge. 

Utensils  and  Linen. — The  next  lesson  is  in  the  care  of 
utensils,  but  not  of  instruments  delicate  in  construction  and 
difficult  to  obtain.  It  is  wrong  to  place  the  instruments  in 
the  hands  of  a  greenhorn.  She  who  passes  instruments, 
knowing  which  and  how  many  she  has  laid  out,  must  put 
them  away,  with  help,  of  course,  to  break  in  her  juniors 
who  usually  get  through  before  her,  but  so  that  she  may 
carry  the  responsibility  of  their  count  and  condition — 
especially  keeping  them  in  a  fixed  place  on  the  shelves 
that  everybody  will  know,  and  in  an  order  that  has  some 
anatomic  science  at  its  basis.  But  the  new  nurse  may 
scrub  basins,  baskets,  tubs  and  faucets,  and  sort  linen 
for  the  laundry,  washing  off  all  clots  before  it  goes  down 
the  chute.  By  cooperation  with  the  laundry  a  strict 
check  can  be  kept  as  to  who  let  an  instrument  go  down 
the  chute,  a  small  pillow,  or  a  rubber  sheet,  particularly 
when,  as  a  disciplinary  measure,  the  lost  articles  are 
returned  via  (1)  the  superintendent's  office,  and  (2)  the 
superintendent  of  nurses'  desk.  At  many  more  times 
in  the  day  than  from  the  other  chutes  the  laundry  clears 
away  the  linen  from  the  operating-room  chute,  which 
should  be  situated  separately  from  the  others  where  they 
debouch  on  the  lower  floor,  and  by  the  hours  when  it  is 
emptied  and  by  the  articles  found  strict  account  can  be 
held  of  the  nurses  on  duty  at  that  time.  "Make  haste 
slowly"  with  linen,  instruments,  and  anything  else  in 
hospital  equipment,  for  all  of  it  is  of  untold  value  when  one 
wants  it  and  has  not  any  chance  of  getting  it.  A  repri- 
mand for  such  carelessness  should  be  enough,  but,  if  fol- 
lowed by  a  repetition  of  the  offence,  the  supervisor  would 
be  justified  in  withdrawing  some  of  the  pupil's  privileges 
or  honors.  The  superintendent  of  nurses  is  deeply  con- 
cerned here,  and  is  not  truly  fulfilling  the  obligations  of  her 


28  OPERATING   ROOM 

office  if  she  is  afraid  or  too  busy  to  .visit  the  operating 
room  often  and  know  all  its  workings.  The  operating- 
room  supervisor  is  beneath  her  in  rank  and  the  two  must 
work  in  unison.  A  new  superintendent  of  nurses  cannot 
expect  to  change  all  the  o'perating-room  methods,  to  the 
dismay  of  the  surgeons,  deepened,  perhaps,  by  the  innuen- 
does of  an  inethical  operating-room  supervisor.  Both 
women  would  be  at  fault.  The  newcomer  must  study 
the  situation  first  in  its  entirety,  and  only  where  it  is 
inefficient,  if  she  is  clever  enough  to  detect  it,  should  she, 
by  cooperation  with  the  surgeons,  correct  the  faults  on 
the  basis  that  her  pupils  must  get  the  best  training  to  be 
had.  It  is  no  longer  necessary  (to  return  to  the  point 
whence  the  digression  was  made)  to  count  linen  daily. 
A  modern  building  is  so  equipped  and  laid  out  that  linen 
cannot  be  stolen  from  it.  The  employees  file  out  of  one 
door  past  the  offices,  and  cannot  carry  bundles  or  pad 
their  persons  without  exciting  suspicion.  The  supplies 
for  operating  are  of  a  different  texture,  pattern,  and  make 
from  the  ward  goods,  and  are  marked  distinctly.  •  Ward 
supervisors  finding  operating  linen  in  their  stock  should 
return  it  to  its  proper  place  at  once,  and  report  the  same 
to  the  head  laundress,  to  have  the  error  in  her  depart- 
ment corrected.  The  "dirty"  nurse  who  sends  down 
the  linen  should,  as  a  part  of  her  training,  see  it  through 
the  laundry  a  few  times,  and  have  charge  of  it  when  it 
comes  back,  so  that,  knowing  now  exactly  how  long  it 
will  take,  she  can  keep  tab  on  every  piece.  When  the 
patients  are  taken  to  the  ward,  every  blanket  or  towel 
must  be  brought  back  and  sent  down  the  operating-room 
chute,  not  the  ward  chutes,  lest  time  be  lost  owing  to 
their  less  frequent  service.  A  ward  pupil  "receiving" 
the  ether  patient  must  go  over  her  with  a  fine-tooth  comb 
to  learn  her  condition  so  minutely  that  she  pounces  at 
once  on  any  foreign  body  such  as  an  operating-room 
chest  blanket  or  pus-basin. 

Building  the  stretcher  is  a  lesson  for  the  first  day.     In 
all    lessons    the    supervisor,    demonstrating,   emphasizes 


OPEEATING-ROOM    PUPILS  29 

the  points  on  which  former  pupils  failed,  and  after  doing 
the  actual  work,  watches  the  pupil  do  it  over.  If  the 
latter  makes  mistakes,  she  must  do  it  again  until  she 
does  it  properly. 

Classes  in  Anatomy. — The  new  "unscrubbed"  nurse 
need  not  be  kept  entirely  out  of  the  anatomic  features  of 
the  cases.  She  is  present  each  morning  at  the  small  class 
held  by  the  supervisor  before  a  skeleton  and  a  set  of 
anatomic  charts  in  the  work-room,  where,  briefly  but 
tersely,  she  sketches  the  site  of  each  wound,  hernia, 
cholecystectomy,  or  iridectomy,  going  more  minutely, 
perhaps,  into  it  with  the  nurse  at  the  instrument-table. 
Here  she  builds  for  the  future.  The  best  supervisor  is 
she  who  turns  out  the  best  finished  products,  "good 
futures"  in  operating-room  nurses,  as  they  say  in  the 
cotton  market.  It  is  not  by  isolating  herself  to  fold  cool, 
unimpassioned  linen,  talking  with  interns,  making  rounds 
through  the  wards,  playing  politics  with  the  surgeons,  or 
doing  all  the  hard  and  delicate  skilled  work  herself  that 
a  supervisor  helps  the  hospital  most  fully.  When  pupils 
read  these  pages  let  them  be  assured  that  the  hardest 
days  they  spend  on  this  service  are  the  days  of  which  they 
will  be  proudest  by  and  by,  indeed,  as  soon  as  they  get 
rested. 

No  head  nurse  can  teach  all  she  knows.  No  Latin 
master  can  give  his  pupils  all  his  knowledge.  But  the 
hints  and  suggestions  from  attendants  and  interns  who 
have  watched  many  other  operators  and  visited  many 
other  operating  rooms  should  be  heartily  welcomed. 
No  pupil  can  absorb  all  she  hears.  It  would,  therefore, 
be  a  sorry  world  if  there  were  not  a  good  safe  way  to  avoid 
these  two  glaring  defects.  Make  the  pupil  self-reliant. 
Do  not  try  to  cram  her  mind  with  facts,  but  teach  her 
how  to  know  when  she  is  ignorant,  and  where  to  go  for  in- 
formation. There  are  charts,  books  of  rules,  anatomy 
and  materia  medica  text-books,  surgeons,  and  nurses  to 
consult  when  she  is  in  doubt. 

Impartiality. — Nurses  in  the  operating  room  should  not 


30  OPERATING  ROOM 

be  bribed  or  coaxed  to.  lend  themselves  to  the  especial 
aggrandizement  of  any  one  surgeon.  The  doctors  should 
maintain  a  strictly  impersonal,  business  relation  with  them, 
and  vice  versa.  Favors  arising  in  the  operating  room  to 
one  man,  though  bestowed  by  a  pupil,  cause  fusses  all 
over  the  institution.  A  pupil  must  know  that  she  is  not 
to  be  swayed  by  emotion  here  above  all  places  in  the 
hospital.  She  must  do  for  one  only  what  she  does  for  all, 
whether  it  be  lending  instruments,  giving  out  supplies,  or 
rendering  more  devoted  service  herself.  There  are  rules 
written  and  unwritten  that  must  be  observed  to  keep  an 
honorable  course  and  a  clean  conscience.  To  act  fairly 
and  squarely  toward  the  Directors,  the  Medical  Board, 
the  hospital  staff,  and  the  municipality  is  the  largest  and 
noblest  interpretation  of  good  operating-room  work. 

Relation  Between  the  Operating  Room  and  the  Ward.— 
Operating-room  work  is  studiously  omitted  in  most  state 
requirements,  and  yet  it  is  the  chief  work  of  some  private 
nurses  going  out  to  "set  up,"  assist,  and  care  for  the 
patient  until  she  is  "over  the  operation."  Others  make 
a  livelihood  as  office  nurses  where  all  minor  surgery  is 
performed.  As  the  heads  of  clinics,  others  yet  have  to 
command  as  much  knowledge  of  surgery  as  the  retiring, 
secluded  operating-room  nurse.  The  superintendent  of 
nurses  must  be  familiar  with  all  these  fields,  and  have  a 
secure  feeling  that  her  pupils  are  being  equipped  for 
these  things  so  as  to  reflect  credit  on  her. 

One  tactful  pupil  can  dissolve  the  antagonism  of  years 
between  wards  and  operating  room  by  helping  out  the 
former  in  the  thousand  little  crises  that  daily  occur  in  this 
earnest  life.  (1)  If  a  ward  is  anxious  to  have  "hot  things 
hot"  for  a  case  in  shock  as  it  goes  down,  she  can  keep 
them  posted  by  phone  as  follows:  "They  have  just  finished 
sewing  up."  (2)  If  a  surgeon  intends,  after  operating,  to 
do  some  difficult  "stunt"  on  the  ward,  which  is  not  ex- 
pecting it,  she  can  telephone  to  that  ward,  "Dr.  -  -  is 
going  to  snip  the  frenum  under  Baby  -  — 's  tongue,  or 
retract  the  foreskin,  or  ligate  his  extra  thumb,"  because, 


OPERATING-ROOM    PUPILS  31 

on  the  other  hand,  it  is  a  very  mirthful  moment  on  the 
wards  when  the  operating-room  forgets  a  sponge  or  a 
piece  of  drainage.  If  a  pupil  in  her  first  six  months  has 
shown  qualities  that  do  not  make  for  integrity  and  in- 
dustry, endurance  and  foresight,  she  should  be  denied  the 
training.  Why  tantalize  a  valuable  supervisor?  Why 
vex  a  surgeon?  Why  endanger  a  patient's  life? 

After  reprimands,  if  the  pupil  makes  good,  let  her 
take  the  training.  If  again,  during  the  first  weeks  of  her 
operating  service,  she  falls  from  grace,  pursue  the  same 
course.  Many  pupils  have  gone  through  their  hospital 
work  in  a  mechanical  way;  but  such  is  the  genius  of  the 
American  people  for  organization  that  the  modern  girl 
catalogs  what  the  hospital  has  to  offer  before  entering, 
and  asks  for  what  she  fears  she  will  miss.  Many  girls' 
training  has  been  absolutely  unbalanced,  too  much 
night  or  medical  or  surgical  work,  and  this  is  wrong. 
But  they  all  endow  with  some  very  mysterious  honor  the 
operating-room  service,  and  they  ought  to  earn  it,  getting 
it  preferably  at  the  end  of  the  first  year. 

Deportment. — The  pupils  must  be  of  military  deport- 
ment in  obedience  to  each  other,  according  to  rank,  in 
the  matter  of  work,  at  the  same  time  preserving  a  humane 
friendliness  in  the  matter  of  help  and  privileges.  It  is 
not  fair — and  the  supervisor  should  step  in  here — for  one 
nurse,  who  is  very  fond  of  going  out,  to  " trade  nights" 
with  a  conscientious  "drudge"  who  has  no  place  to  go; 
nor  should  one  plead  "malaise"  or  "migraine"  oftener 
than  another.  When  a  pupil  from  the  wards  which  may 
seem  extravagant  comes  up  to  beg  for  dressings,  she  should 
not  be  met  with  savage  looks.  If  her  ward  uses  too 
much,  its  staff  should  come  after  hours  and  help  make 
them  or  help  sterilize  them.  The  same  thing  may 
happen  when  they  are  in  reversed  positions.  Besides, 
there  should  be  limitless  supplies  for  drainage  cases, 
such  as  fecal  fistulse,  gall-bladders,  and  "pus  appendices," 
which  the  operating  staff  should  inquire  about  and 
study  carefully. 


32  OPERATING   ROOM 

Eight-hour  duty  is  just  as  possible  in  an  operating  room 
as  in  a  ward.  There  are  more  pupils  needed  for  this 
system  in  any  ward  or  division.  The  chief  argument 
opposed  to  it  is  "responsibility,"  but  on  account  of  the 
minute  subdivision  of  all  labor  it  means  nothing.  Miss 
A.  can  scrub  up  and  come  in  to  relieve  Miss  B.  on  instru- 
ments as  soon  as  she  knows  "where  the  surgeon  is  at," 
silently  and  unobtrusively,  just  as  well  as  any  other  time, 
as  long  as  the  supervisor  remains  through  the  case. 
Where  the  pupils  are  of  vastly  unequal  skill,  operations 
should  be  booked  with  this  in  view.  For  night  work 
there  should  be  pupils  on  the  wards  who  "have  had 
operating  room"  and  can  "take"  any  emergency.  The 
supervisor  should  not  have  her  rest  broken  year  in  and 
year  out,  with  such  meager  pay  that  she  cannot  insure  or 
pension  herself.  The  pupils  always  do  well,  and  the  doc- 
tors help  them  more  when  left  to  themselves.  Some 
hospitals  put  a  nurse  on  regularly  from  noon  to  midnight 
to  bear  the  brunt  of  the  night  work. 

Priority  of  service  on  a  ward  comes  before  seniority 
in  the  school  when  an  operating  nurse  relieves.  The  ward 
nurse  may  be  a  junior,  and  yet  have  all  her  ward  affairs 
at  her  clever  finger-tips.  An  operating-room  pupil  who 
may  go  there  for  a  half -day  or  a  Sunday  should  fit  in  grace- 
fully, bowing  to  the  judgment  of  the  superintendent,  the 
power  behind  the  throne,  instead  of  sulking,  loafing,  or 
picking  faults. 

Certain  hospitals  have  given  their  most  capable  pupils 
scholarships  in  cash,  from  $50  to  $100,  as  pin  money  to 
use  while  taking  postgraduate  work  by  the  gracious  con- 
sent of  some  large  recognized  institution  which  receives 
the  outsider  and  gives  her  her  chances,  home,  and  ac- 
commodations in  return  for  her  labor.  This  gift  fre- 
quently comes  from  the  private  treasure  of  one  member 
of  the  board,  but  it  is  a  good  practice  to  establish  in  all 
schools,  for  all  grades  of  work,  through  the  auspices  of  the 
whole  body  of  governors.  Some  nurses  may  be  averse 
to  surgery  and  yet  wish  to  devote  themselves  to  the  care 


OPERATING-ROOM    PUPILS  33 

of  children,  and  they  should  stand  an  equal  chance  of 
such  a  scholarship. 

Self-government  is  a  priceless  boon  to  the  nurse — as 
inaugurated  in  many  Western  universities — and  a  vote 
by  the  nurses,  serious  and  well-pondered,  should  be  a  big 
factor  in  awarding  these  scholarships. 

All  visitors,  whether  confessors  or  messengers,  must  be 
received  with  courtesy,  and  the  burden  of  their  being  in 
that  "Holy  of  Holies"  placed  on  the  office,  where  it  be- 
longs. This  is  a  part  of  the  nurse's  training  to  "get  along 
with  the  relatives"  in  private  work.  So  great  is  the  bond 
of  affection  in  some  families  that  the  lonesome  cry  of  the 
dying  must  be  answered  despite  red  tape  and  frowning 
walls:  "Come  with  me,  granny,  come  with  me!  I  canna 
gang  alone!" — and  granny  says,  with  brave  eye,  but 
trembling  lip,  "I'll  gang  wi'  ye,  laddie,  as  far  as  ever  I 
can." 

Genito-urinary  Work. — It  has  been  at  different  times 
and  in  different  states  a  burning  problem  whether  pupil 
nurses  should  be  present  at  genito-urinary  operations 
(male  cases).  The  surgeons  of  the  old  school  are  the  ad- 
visors of  today,  and  having  had  their  experience  in  the 
old-fashioned  way,  where  the  nurse  was  present  at  all 
operations,  the  gist  of  their  counsel  is  to  do  the  same 
with  the  modern  pupil.  Why  not  leave  it  to  the  option 
of  the  pupil?  She  is  a  separate  entity,  and  need  not  take 
the  whole  of  the  system  prescribed  for  her,  holus-bolus,  by 
people  who  do  not  know  how  a  woman  feels,  especially 
since  .the  whole  operating-room  period  is  omitted  in  the 
schedule  of  some  states  for  nurses'  training.  In  any 
university  a  man  has  the  option  of  classics  or  modern 
languages,  science,  or  arts.  The  future  career  of  a  nurse 
can  decide  her  present  choice  for  her.  If  she  wishes  to  do 
army  and  navy  work,  district  work,  etc.,  she  may  decide 
to  study  genito-urinary  work,  and  the  opposite  holds 
equally  well.  The  ward  work  acquires  no  new  skill  from 
the  fact  that  the  nurses  are  present  at  these  operations. 
The  anatomic  nature  of  these  cases  is  such  that  the  rigid 
3 


34  OPERATING  ROOM 

asepsis  of  abdominal  cases  is  not  applicable  or  necessary. 
Besides,  orderlies  can  be  taught  to  become  quite  skilful 
in  waiting  on  the  surgeons,  and  if  reliable  and  well  paid 
remain  steadily  on  the  staff,  much  more  to  the  surgeon's 
advantage  than  the  changing  pupils.  The  extreme 
youth  of  the  average  pupil  at  present  must  be  considered, 
too,  in  comparison  to  the  age  of  the  nurses  of  ten  or 
twenty  years  ago.  When  the  nurse  is  doing  private 
duty  after  graduation  she  seldom  if  ever  '  'specials"  a 
"g.-u."  case  outside  of  hospital  walls,  and  this  work  is 
usually  assigned  by  any  thoughtful  superintendent  to 
the  older  women,  for  many  good  reasons  that  need  not  be 
specified.  Why,  then,  force  this  part  of  operating-room 
work  on  an  unwilling  pupil?  The  work  can  be  easily 
cared  for  in  the  operating  room  by  interns,  who  will  un- 
doubtedly have  in  their  future  office  practice  a  very  large 
percentage  of  this  work,  and  who  are  naturally  very 
eager  to  learn  to  relieve  these  conditions.  Then,  again, 
in  private  practice,  a  nurse  following  this  branch  of 
work  is  alone  with  her  patient,  while  a  surgeon  always 
provides  himself,  in  gynecology,  with  the  chaperonage 
and  assistance  of  an  office-nurse  or  a  relative  to  protect 
himself  from  slanderous  tongues,  just  as  much  as  to  pro- 
tect the  patient.  These  questions  are  entitled  to  discus- 
sion by  impartial  modern  minds  of  lay  committee  mem- 
bers as  well  as  surgeons. 

Moving  Pictures. — By  a  little  additional  expense  a 
moving-picture  system  can  be  established  in  the  operating 
room  for  the  education  of  the  pupils,  in  which  the  field  of 
operation  is  shown  every  inch  of  the  way,  also  the  in- 
strument table,  so  that  a  nurse  can  easily  learn  why  she 
must  provide  certain  instruments  and  dressings.  It  will 
soon  be  possible,  when  a  supervisor  presents  the  day's 
schedule,  to  turn  on  a  reel  and  a  phonograph  simulta- 
neously, to  see  the  actions  and  hear  the  explanations  of  a 
surgeon  removing  a  ureteral  calculus,  or  performing  a 
herniotomy,  or  again,  transplanting  a  graft  from  a  tibia 
to  a  spine  for  Pott's  disease,  ununited  fracture,  or  to  an- 


OPERATING-ROOM    PUPILS  35 

kylose  a  knee-joint.  The  nurse  who  has  to  "set  up"  for 
a  certain  case  will  be  enabled  to  see  just  when  the 
"spurters"  will  spurt,  so  as  to  know  when  to  hand  a  liga- 
ture, or  to  see  when  the  bone-dust  ("sawdust")  flies,  so 
as  to  lay  anew  a  sterile  towel.  This  is  the  only  way  to 
solve  the  ancient  difficulty  voiced  in  a  plaintive  tone  by 
thousands  of  nurses:  "But  I  never  can  tell  what  he  is 
doing!" 


CHAPTER  II 
THE   JUNIOR  NURSE 

"Life  is  a  patchwork  quilt,  stitched  on  the  background  of  Eternity, 
and  padded  out  with  the  rags  of  Time.  Strange  colors  we  introduce! 
Here  a  dash  of  scarlet  Passion,  there  a  scrap  of  pure  white  Faith, 
then  brown  Doubt  and  pale  green  Ennui !  Most  of  us,  however, 
have  to  fall  back  on  the  dull  drab  of  Work  to  fill  out  the  spaces, 
and  thank  God  for  it,  for  it  rests  the  tired  eyes." 

Quoted  from  an  old,  old  issue  of  Toronto  " Varsity";  student 
author  unknown. 

Her  Numerous  Duties. — This  nurse's  work  seems 
hardest  because  it  is  new  and  apparently  disconnected, 
a  heterogeneous  mass  of  "chores,"  a  bewildering  waiting 
on  four  people  at  once,  all  of  whom  equally  insist  on  im- 
mediate notice,  waiting  for  others  to  pass,  finishing  up 
what  others  begin,  and  jumping  at  every  one's  beck  and 
call.  Yet  the  " floater"  is  indispensable. 

She  must  dust  with  a  damp  gauze  cloth  and  a  dry 
linen  or  cotton  one,  Bon  Ami,  and  brown  soap  in  all  the 
rooms  appointed  to  her — the  sterilizing  room,  hopper 
room,  dressing  rooms,  etc. — the  anesthetic  nurse  doing 
her  own  portion  and  the  scrubbed  nurse  the  operating 
rooms.  A  marble  pit  should  be  scrubbed  with  Sapolio 
and  dilute  Labarraque's  solution  at  the  finish  of  each 
day's  operating..  She  scrubs  all  basins  with  Sapolio 
and  dilute  Labarraque's  solution,  or,  if  rusted  in  spots, 
lets  them  stand  at  a  slant,  with  a  weak  solution  of  oxalic 
acid  until  this  disappears.  (Oxalic  acid  must  be  kept  in 
the  poison  closet.)  She  assists  in  moving  unconscious 
patients  and  puts  on  binders  or  bandages,  trying  to  show 
perfect  skill  in  applying  what  she  was  taught  in  previous 
classes.  She  should  be  able  to  do  it  well  before  coming 
to  the  operating  room,  so  as  not  to  keep  a  patient  on  the 
stretcher  until  vomiting  begins.  In  handling  these 
36 


THE    JUNIOR    NURSE 


37 


things  on  the  stretcher  long  footstools  must  be  used. 
A  nurse  cannot  get  any  "purchase"  on  her  work  if  she  is 
too  far  above  or  below  it.  She  may  be  asked  to  "set  up" 


Fig.  1. — Offering  a  glove  case. 


for  cases  shortly  after  entering  on  this  service  by  clean- 
ing the  tables  with  carbolic  acid  (5  per  cent.),  then  selecting 
and  opening  the  proper  table  covers,  and,  after  donning 
her  cap,  scrubbing,  and  donning  a  gown,  laying  these 


38  OPERATING   ROOM 

covers  in  place.  Teaching  the  junior  to  "set  up"  early 
facilitates  running  off  a  full  program.  She  waits  then  on 
the  instrument  nurse — opening  jars,  collecting  empty 
covers,  tying  gowns,  and  keeping  everything  picked  up. 
In  fastening  gowns  she  touches  no  part  of  the  garment 
but  the  tape  nor  the  doctor's  fingers.  In  removing  sterile 


Fig.   2. — Sterilizer  forceps  for  removing  basins  from   the  utensil 

sterilizer. 

goods  (Fig.  1)  she  holds  them  out  from  her  body,  arfd  never 
carries  a  bundle  under  her  armpit.  She  brings  in  the 
boiled  instruments,  holding  them  firmly  at  a  distance 
before  her,  and  not  setting  them  down  (for  she  would  have 
to  reach  over  a  sterile  cover) ,  but  waiting  for  the  nurse  to 
take  them.  She  carefully  washes  all  instruments  that 
fall  on  the  floor  and  boils  them  the  right  length  of  time, 


THE   JUNIOR   NUESE  39 

specified  in  the  house  book  of  rules,  with  her  eye  on  the 
clock  over  the  sterilizers,  from  time  to  time  looking  in  to 
see  if  she  is  needed  in  the  main  room.  Forceps  are  to  be 
used  in  lifting  basins  out  of  the  utensil  sterilizer  (Fig.  2), 
so  that  a  nurse's  body  need  not  hang  over  it.  She  may 
hold  a  sterile  basin  without  letting  her  fingers  come 
over  the  edge  of  it  (compare  with  a  well-taught  maid 
handing  one  a  dish  of  preserved  fruit).  She  fills  this 
basin  with  sterile  water,  holding  it  on  her  palm,  first 
under  the  cold  tap,  second  under  the  hot  for  her  own 
comfort,  and  away  from  her  body,  so  that  possible 
dandruff  will  not  drop  in.  These  solutions  should  be 
tested  by  a  glass  thermometer  kept  in  a  disinfectant, 
lifted  with  forceps,  and  rinsed  with  sterile  water  before 
plunging  into  what  may  go  on  the  eye  or  on  the  bowel. 
If  it  is  too  hot  it  will  burn  the  patient  or  the  surgeon;  if 
if  it  is  too  cold  the  patient  will  be  ''shocked, "  and  at  the 
surgeon's  language  she  herself  will  be  shocked.  She 
drops  a  sterile  towel  by  means  of  the  same  sterile  forceps 
over  the  arm  tank  of  bichlorid  when  all  are  through 
immersing.  She  must  never  take  anything  off  the  sterile 
tables.  The  scrubbed  nurse  must  drop  them  to  her  or 
hold  them  so  that  she  can  grasp  them  in  a  forceps.  She 
must  think  with  every  bit  of  her  outer  clothing.,  i.  e.,  by  prac- 
tice she  learns  to  judge  distances,  so  as  not  to  hang  over 
or  back  against  anything  (Fig.  3).  She  takes  nursing 
charge  of  the  patient  the  moment  the  anesthetic  nurse 
leaves,  giving  the  anesthetist  all  the  supplies  he  needs, 
and  administering  hypodermics  at  his  order  carefully  and 
correctly,  charting  over  her  signature  all  the  data  regard- 
ing same. 

She  washes  and  boils  every  instrument  inadvertently 
dropped,  and  in  bone-plating,  which  demands  most  rigid 
asepsis,  she  resterilizes  every  instrument  every  time  it  is 
used,  therefore  keeping  the  small  sterilizer  boiling.  She 
learns  early  to  run  the  cautery,  practising  without  a 
patient. 

Sponges  now  are,  fortunately,  not  counted,  owing  to 


OPERATING   ROOM 


the  speed  of  operating.  A  surgeon  may  put  one  sponge 
in  the  vagina  as  backing  while  suturing,  but  it  should  be 
simply  a  "coup  d'esprit"  to  remember  it.  It  is  quite  an 
honor  to  be  asked  to  remember  a  plug  or  pledget  some- 


Fig.  3. — Wiping  perspiration  from  a  scrubbed  nurse's  brow. 

where,  and  one  does  as  easily  as  an  invitation  out  to 
dinner,  but  to  ask  a  nurse  to  count  and  handle  a  hundred 
bloody  or  pus-laden  sponges  was  never  right  or  necessary, 
especially  for  two  reasons:  (a)  it  took  her  mind  off  all  the 
instructive  details;  (6)  they  bore  infection. 


THE    JUNIOR    NURSE  41 

She  must  turn  to  the  blanket  warmer  if  the  patient  goes 
into  shock  for  warm  wraps  to  restore  him. 

She  should  be  put  in  the  Trendelenburg  and  the  Sims 
positions  herself  and  then  practise  with  the  fattest  women 
she  can  find,  so  as  to  learn  where  to  adjust  their  knees, 
hips,  etc.  She  must  also  wind  up  the  table,  if  the  anes- 
thetist's mind  .must  be  confined  to  the  anesthetic  alone, 
though  the  modern  tables  make  it  easy  for  him.  She 
wraps  the  patient's  feet  in  a  hot  blanket  so  that  they  will 
not  cool  in  mid  air.  She  must  learn  by  experience  to 
judge  how  long  she  dare  stay  out  of  the  main  room  when 
boiling  up,  going  back  to  the  patient,  watch  in  hand, 
rather  than  be  missing  when  needed.  The  surgeon 
should  never  be  the  one  to  insist  on  getting  an  instru- 
ment before  it  is  boiled  long  enough. 

After  a  case  is  concluded  all  the  work  is  moved  up  a 
notch.  She  washes  and  changes  the  linen  on  the  operat- 
ing-table, where  only  one  is  used,  gathers  up  all  linen, 
throws  bloody  linen  under  the  cold  tap,  puts  on  the 
binders,  cleans  basins,  then  if  she  knows  how  (it  has  been 
already  recommended)  scrubs  up,  and  "sets  up"  while 
the  senior  nurse  selects  other  instruments,  wraps  and 
boils  them,  and  "scrubs  up"  later. 

She  keeps  the  scrub-up  stands  clean  and  supplied  with 
brushes  at  all  times.  Dry  sterilization  and  plenty  of 
brushes  obviate  the  difficulties  formerly  noticed  in  boil- 
ing so  many  kinds  of  things  between  cases. 

She  must  keep  looking  around  for  something  to  do.  Caps, 
masks,  gowns,  suits,  towels,  bandages,  etc.,  are  all  replen- 
ished, and  sterile  sheets  for  the  next  case,  which,  how- 
ever, are  not  opened  until  the  supervisor  begins  to  scrub, 
and  which,  also,  are  limited  by  arrangement  to  fixed 
numbers.  She  cleans  the  sterile  tables  with  carbolic 
acid  1  :  20  before  they  are  reset.  The  operating-table 
is  the  last  thing  to  be  used  (where  the  patient  is  anes- 
thetized on  a  stretcher),  and  the  supervisor  need  not  be 
foolishly  overdriven  by  anyone  in  a  false  haste  of  prepara- 
tion, aiding  herself  by  somewhat  postponing  the  cleaning 


42  OPERATING   ROOM 

of  this  important  piece,  the  changing  of  pillows,  and  wip- 
ing of  the  pad. 

The  dirty  nurse  puts  on  binders.  It  is  very  essential 
to  have  all  sizes  of  good  binders  in  sufficient  numbers, 
and  they  must  be  properly  applied,  for  surgical  reasons. 
Obstetric  binders  press  down  from  above.  For  lapa- 
rotomies,  they  press  upward  from  below.  They  must  be 
measured  around  the  widest  part  of  the  body,  the  curve 
of  the  hips,  and  all  fittings  taken  from  that  point,  darts 
carefully  put  in  both  below  and  above  the  hip  curve  to 
keep  the  pressure  on  the  dressings  secure.  This  is  accom- 
panied by  a  T-binder  for  vaginal  work,  which  has  a  slightly 
different  model  for  male  patients,  being  split.  The 
safety-pins  should  be  rowed  around  the  edge  of  a  piece  of 
Castile  soap. 

An  ordinary  Sloane  breast-binder  with  a  sleeve  added 
makes  an  excellent  binder  for  breast  amputations. 

After  a  first  case  the  room  should  be  cleaned  and  read- 
justed like  magic  if  everyone  knows  her  duty.  The 
bichlorid  solution  in  the  arm  tank  is  changed  for  a  new 
operator,  but  not  for  a  new  case,  unless  used  during  the 
progress  of  a  pus  case. 

The  sterile  basins  for  hand  solutions  are  changed  for 
every  case.  Nothing  used  for  one  case  should  be  used 
for  the  second,  or  touch  anything  that  will  be  used  later. 
If  a  heavy  smear  of  blue  chalk  is  put  unnoticed  on  a 
door  knob  or  some  other  common  object  frequently 
handled  by  all  the  force,  it  gives  a  valuable  lesson  in  the 
transmission  of  invisible  bacteria. 

The  unscrubbed  nurse  watches  visitors,  presents  them 
with  armless  gowns,  and  sees  that  they  do  not  come  in 
contact  with  sterile  tables. 

The  shoulder-pieces  for  Trendelenburg  are  puzzling 
at  first  sight,  but  easily  thought  out.  They  must  be 
well  padded  to  prevent  bruises  or  paralysis  of  the  trape- 
zius  muscle.  The  bar  running  into  the  rings  must  be  well 
nickel-plated,  rustless,  and  lubricated.  The  stirrups  must 
be  similarly  inspected  and  kept  perfect.  The  loops  of  the 


THE    JUNIOR    NURSE  43 

foot-rests  must  be  perfectly  understood,  the  arch  of  the 
foot  resting  on  one  half,  the  tendo  Achillis  on  the  other. 
The  angle  in  each  stirrup,  directed  outward,  is  to  throw 
the  patient's  limbs  farther  apart  to  give  the  operator 
more  room.  In  lithotomy,  the  patient's  buttocks  must 
hang  over  the  end  of  the  table  so  as  to  relax  all  the  soft 
parts,  and  the  Kelly  pad  should  not  slide  down  too  far 
when  the  patient  is  placed  "in  situ."  The  apron  of  the 
pad  must  fall  from  the  angle  at  which  it  is  made. 

The  unscrubbed  nurse  may  have  to  record  the  number 
of  pairs  of  gloves  or  tubes  of  catgut  used  in  an  operation 
if  the  office  makes  specific  charges  to  the  patient  for 
these. 

As  several  operations  succeed  one  another  with  great 
celerity,  and  the  specialists  desire  to  take  home  their  in- 
struments, the  junior  nurse  must  at  this  period  learn  the 
mechanism  of  every  cautery,  cystoscope,  tonsil  snare,  or 
rheostat.  Then  she  can,  with  the  probable  aid  of  the 
anesthetic  nurse,  clean  them  and  put  them  together  while 
their  owner  is  in  the  shower-bath  and  the  next  case  safely 
started.  It  helps  greatly  to  have  them  soaking  in  cold 
water  to  loosen  bloody  particles,  but  this  does  not  apply 
to  some  parts  of  a  cystoscope,  etc.,  that  are  never  wet. 
While  one  case  is  being  sutured,  the  scrubbed  nurse  should 
hand  her  junior  all  the  instruments  that  will  be  needed  for 
the  next  except  the  suture  set,  to  be  washed  and  started 
boiling.  In  a  busy  operating  room  much  time  is  saved 
by  putting  each  surgeon's  instruments  into  separate  large 
basins,  of  which  there  should  be  many,  if  they  cannot  be 
immediately  cleaned,  tagging  each  basin  with  the  name 
of  their  owner.  It  is  very  easy,  by  using  the  brain  be- 
hind one's  eyes,  to  learn  each  man's  instruments,  but  it  is 
impossible  if  one's  mind  is  on  plays  and  dances  during 
work  hours. 

By  dusting,  the  junior  learns  where  everything  is  and 
acquires  the  "location"  habit. 

She  must  instantly  provide  boric  acid  and  argyrol  if 
pus  squirts  into  the  surgeon's  eyes,  and  carbolic  acid  and 


44  OPERATING   ROOM 

alcohol  with  a  clean  probe  if  he  jabs  his  finger  with  a 
needle. 

When  patients  require  catheterization,  she  saves  the 
specimen,  and  marks  it  at  once  with  the  patient's  name, 
not  daring  to  trust  her  memory,  whether  she  is  told  to  do  so 
or  not.  In  cystoscopic  work,  she  marks  the  left  and  right 
specimens  with  perfect  accuracy,  knowing  this  involves 
life  or  death  for  the  patient. 

She  stands  with  the  specimen  basin  (given  her  without 
contact  by  the  scrubbed  nurse),  holding  it  from  below,  so 
that  if  the  surgeon  inadvertently  touches  it  when  he  lays 
down  the  specimen  he  shall  receive  no  contamination  from 
her.  Dermoid  cysts,  fetuses,  and  all  other  solids  are 
saved  as  a  routine,  and  preserved  in  formalin  (4  per  cent.). 
Getting  this  habit  prevents  one  from  absent-mindedly 
throwing  away  some  priceless  thing. 

She  can  instantly  procure  sandbags  of  the  right  shape 
and  size  to  adjust  a  head  or  limb  to  the  surgeon's  fancy. 

She  slaps  ice  towels  on  tonsil  cases  to  restore  con- 
sciousness and  good  circulation,  or  to  relieve  hemorrhage. 
She  deftly  turns  the  tonsil  cases  in  their  special  long  rubber 
sheet  (2  yards  by  \  yard)  so  that  they  bleed  into  the  pail 
at  the  surgeon's  feet,  where  he  may  look  for  specimens 
and  judge  the  amount  of  bleeding. 

She  prepares  all  solutions,  irrigations,  douches  for  hem- 
orrhage, enemata,  etc.,  and  must  be  sure  of  her  formulae 
and  accurate  in  their  temperature,  using  a  sterile  ther- 
mometer every  time,  kept  in  a  harmless  antiseptic  solu- 
tion and  plunged  into  the  fluid  by  sterile  forceps. 

She  is  the  logical  person  to  prepare  for  intravenous 
infusion,  lumbar  puncture,  or  hypodermoclysis  "on  the 
table"  without  any  agitation  or  mistakes. 

After  a  long  ether  anesthesia  she  brings  the  lavage 
set,  with  a  bucket  for  the  return,  and  a  pan  of  ice-water 
for  a  lubricant.  This  is  also  usual  in  peritonitis  cases. 

When  she  gets  a  hint  that  the  patient  will  be  a  drain- 
age case  she  asks  if  a  Gatch  bed  will  be  used,  and  tele- 
phones this  to  the  ward,  so  that  the  ether  bed  will  be  al- 


THE    JUNIOR    NURSE 


tered  in  time  for  all  to  be  in  complete  readiness  when  he 
goes  down.  This  avoids  delay  in  making  him  comfortable, 
and  is  much  easier  than  with  a  stretcher  beside  the  bed 
when  the  change  is  effected  in  the  ward. 


'  ^^Hhlyte-' 

4' 


Fig.  4. — Dusting  aristol  on  a  wound. 

She  telephones  general  messages  to  the  office  or  ward 
at  the  will  of  the  surgeon  or  intern,  or  writes  (and  initials) 
orders  in  the  ward  order  book  at  their  dictation,  vised  by 
the  anesthetist. 

She  keeps  work  going  on  all  the  time  behind  the  scenes 


46  OPERATING   ROOM 

—linen  soaking,  washing  or  drying  gloves,  sorting  covers 
as  she  takes  them  out,  or  running  the  big  sterilizers. 

She  must  drop  acetanilid,  aristol,  or  collodion  on  a 
new  wound  in  an  aseptic  manner,  wiping  off  the  con- 
tainer with  a  bichlorid  compress,  and  delicately  winding 
a  sterile  towel  around  her  right  arm  (Fig.  4). 

She  puts  on  any  tourniquet  for  amputation  or  intra- 
venous infusion,  knowing  the  anatomy  of  the  parts. 

She  is  instructed  by  the  engineer  personally  about  all 
lights,  switches,  fuses,  valves,  stop-cocks,  faucets,  cold 
coils,  water  jackets,  steam  jackets,  pet-cocks,  foot-treads, 
gages,  sprays,  soapholders,  waste-pipes,  traps,  and  other 
forms  of  steam-fitting,  plumbing,  and  electricity,  accord- 
ing to  a  list  drawn  up  by  him  and  the  supervisor.  When 
nurses  are  taught  these  things  it  reduces  the  stoppage  of 
pipes,  etc.,  to  almost  nothing. 

She  must  shave  an  emergency  case  or  one  improperly 
prepared  "dry"  with  a  steady  hand  and  in  a  perfect 
manner.  This  necessitates  frequent  practice  on  the 
wards  previously. 

If  there  are  flies  in  the  vicinity  they  must  be  swatted 
(the  woven  wire  bound  in  velvet  being  best),  and  all 
doors  must  be  closed  during  a  case. 

When  the  "unscrubbing"  nurse  cleans  the  instrument 
cabinets  she  learns  where  to  find  things  in  a  hurry  by 
then  asking  what  each  is,  and  for  what  it  is  used,  each 
shelf  having  its  list  of  contents  on  a  card  lying  in  one 
corner,  in  the  order  in  which  they  are  found,  from  left  to 
right.  She  replenishes  the  basin  of  calcium  chlorid  now 
deliquescent,  used  to  keep  down  the  humidity. 

She  has  a  stock  there,  too,  of  smear-glasses,  slides,  and 
swabs  ready  for  immediate  use. 

In  genito-urinary  cases  the  scrubbed  and  junior 
nurses  wait  on  the  operator  from  behind  screens.  In 
hernia  no  expose*  is  necessary  if  extra  towels  be  used 
under  the  laparotomy  sheet.  If  nurses  are  excused  or 
protected  by  a  screen,  they  must  render  excellent  assist- 
ance none  the  less. 


THE    JUNIOR    NURSE  47 

Black  rubber  tracheotomy  tubes,  ivory-handled  knives, 
etc.,  must  not  be  boiled  in  a  moment  of  thoughtless  haste, 
ruining  the  shape  of  one  and  the  material  of  the  other. 

The  junior  nurse  must  listen  avidly  to  the  words  of 
every  actor  in  this  drama,  but  not  to  others.  By  know- 
ing what  they  say  she  can  make  a  shrewd  forecast  about 
what  they  will  want, next. 

The  junior  class  is  given  instruction  in  bandaging, 
even  in  their  preliminary  training,  and  they  must  practice 
on  each  other,  on  convalescent  patients,  and  on  the  sick 
patients  finally,  timing  themselves,  and  working  under 
inspection,  so  that  they  can  put  on  any  bandage  in  the 
operating  room  if  necessary.  In  the  past  it  has  been 
so  badly  done  that  the  surgeons  do  it  themselves,  not 
hoping  to  find  anyone  who  can. 

When  the  supervisor  habitually  "scrubs,"  the  junior 
is  put  in  a  hard  position,  being  unable  to  confer  with  her 
in  a  crisis.  She  must  whet  all  her  senses  to  ten  times 
their  previous  sharpness,  remembering  that  here  not  the 
nurse  is  in  charge,  but  a  man  who  is  under  great  tension 
due  to  the  bigness  of  the  stakes.  He  may  only  jerkily 
ejaculate  his  needs  and  get  angry  if  not  understood. 

The  junior  nurse  is  the  "eyes  and  ears  and  feet"  of  the 
staff,  who  may  not  leave  their  places.  She  must  know 
their  thoughts,  and  feel  with  their  sense  of  touch,  and  see 
with  their  vision. 

After  a  laparotomy,  when  vaginal  drainage  is  desired, 
the  operator  slits  the  culdesac  of  Douglas,  and  passes 
down  a  piece  of  drainage  (never  from  below  up)  into  the 
bite  of  a  uterine  dressing  forceps  held  in  the  vagina  by  the 
junior  nurse  with  a  gloved  hand.  This  sterile  glove  must 
be  ready.  The  nurse  cannot  do  this  well  if  she  has  not 
an  accurate  idea  of  the  relative  position  of  the  bladder, 
uterus,  and  rectum.  It  requires  a  drawing  or  chart  in  the 
supervisor's  morning  lesson. 

A  small  bunch  of  twigs  (especially  birch)  is  useful  in 
whipping  out  the  fibrin  of  blood-clots  when  searching  for 
specimens. 


48  OPERATING    ROOM 

To  give  an  enema  in  haste  the  set  should  always  be 
in  readiness. 

Washing  soda  should  not  be  used  in  aluminum  pans, 
nor  on  the  aluminum  handles  of  instruments. 

A  patient  should  always  be  protected  from  the  cold 
rubber  of  a  Kelly  pad  by  a  large  soft  towel.  This  pad  is 
thoroughly  scrubbed  after  each  case  and  soaked  in 
bichlorid.  Some  surgeons  think  it  is  never  "clean." 

When  messages  come  in  from  the  outside  the  junior 
nurse  must  transmit  them  exactly,  realizing  their  im- 
portance for  the  doctor  or  the  family  needing  him.  There 
should  be  a  pad  of  typed  blank  forms  for  this  at  the  tele- 
phone. 

Perspiration  in  the  axillae  is  inexcusable.  The  nurse 
must  bathe-  twice  a  day  if  necessary,  use  plenty  of  un- 
scented  powder,  and  wear  shields  washed  daily  and  dried 
in  the  sun. 

For  her  owu  benefit,  to  save  back-bending  and  for  the 
cleanliness  of  everything  she  handles,  garbage  cans  should 
open  by  a  patent  foot-tread. 

Special  Beds. — A  case  in  which  the  bladder  has  been 
accidentally  slit  requires  special  instructions  to  the  ward 
about  making  the  bed.  The  top  and  bottom  sections  of  a 
three-piece  mattress  are  used,  but  in  the  center  are  laid 
four  pillows  longitudinally  (two  deep  and  two  on  each 
side),  so  that  when  she  is  laid  on  her  face  the  retention 
catheters  drop  through  into  a  urinal  tied  in  the  center 
of  the  spring  beneath.  The  pillows  are  each  covered  with 
rubber,  and  the  whole  bandaged  into  position.  The  same 
holds  for  certain  fracture  cases  in  the  disposal  of  a  bed-pan. 

For  a  Murphy  drip  the  nurse  can  most  easily  get  at 
her  patient  if  the  covers  are  divided  in  the  center  laterally. 
Protect  the  patient  with  a  soft  warm  covering.  Take 
four  old  blankets  and  fold  each  in  half  laterally.  Spread 
a  sheet  over  the  bed,  and  on  its  upper  half  lay  two  blankets ; 
then  bring  up  over  them  the  bottom  half  of  the  sheet, 
tucking  it  under  their  upper  edge,  and  its  under  edge  out 
over  all  as  usual  with  any  counterpane.  Lay  another 


THE    JUNIOR    NURSE  49 

sheet  over  the  bed,  its  bottom  edge  reaching  barely  to  the 
edge  of  the  mattress.  On  its  lower  half  lay  the  two 
remaining  blankets,  and  turn  the  sheet  down  over  them 
in  order  to  tuck  it  in  at  the  foot.  Pin  the  two  sets  to- 
gether over  the  patient's  hips.  This  permits  any  ad- 
justment of  a  Murphy  drip,  etc.,  without  disturbing  the 
patient,  and  is  excellent  for  a  colon  irrigation.  Being 
ordered  from  the  operating  room  it  slightly  concerns  this 
chapter. 

Gatch  beds  may  be  improvised  by  a  back-rest,  a  pillow 
with  a  rubber  cover  to  sit  on,  a  small  board  under  it  on  a 
long  sheet  folded  many  times  over,  diagonally,  into  a  sling 
fastened  at  the  head  of  the  bed  frame,  extra  pillows  for 
the  back  and  arms  to  rest  on,  and  a  rubber-covered  pillow 
under  the  knees.  A  second  long  sheet  sling  with  a  folded 
sheet  may  be  used  as  a  foot-rest,  tied  to  the  parallel  bars 
under  the  spring.  The  quick  transmission  of  sugges- 
tions for  such  a  preparation  facilitate  the  maintenance  of 
very  friendly  relations  between  operating  room  and 
ward. 


CHAPTER  III 
THE  ANESTHETIC  NURSE 

Positions  for  Operation. — This  nurse's  duties  are  so  de- 
tailed that  she  will  seem  to  need  a  whole  book  to  herself. 
She  first  learns  how  to  place  patients  in  the  various 
"positions"  required  for  operating  from  demonstrations 
by  the  supervisor  on  the  living  subject.  There  are  always 
convalescents  in  the  women's  ward  who  enjoy  being  thus 
honored.  There  is  no  use  in  preparing  a  patient  for  a 
position  until  she  is  thoroughly  relaxed  by  her  anesthetic, 
i.  e.,  when  the  anesthetist  gives  the  order.  Then  it  can 
be  done  quite  easily.  It  is  better  to  call  for  assistance 
than  to  take  too  long  or  to  maul  the  patient  about,  since 
the  tissues  are  most  easily  bruised  when  one  is  under  an 
anesthetic.  Some  patients  are  very  obstreperous,  there- 
fore wide  bandages,  sheets,  etc.,  for  mild  restraint  must 
always  be  at  hand.  Neither  nurse  nor  orderly  should 
throw  himself  across  the  abdomen  of  a  struggling  patient 
whose  appendix  is  about  to  rupture.  The  restraint  neces- 
sary must  not  be  applied  to  the  diseased  part.  Some  most 
mysterious  bruises,  high  on  the  shoulders — e.  g.,  in  an  ap- 
pendix case — can  only  be  accounted  for  by  having  forced 
the  patient  down  on  the  table. 

(1)  Dorsal  Position. — The  patient  is  flat  on  her  back, 
but  her  knees  are  flexed,  so  that  her  heels  are  near  and  on 
a  level  with  her  hips. 

(2)  Kidney   Position. — The   patient   lies   on   her  face 
with  her  arms  above  her  head,  and  a  cylindric  rubber 
bag  inflated  with  air  under  her  abdomen,  to  push  up  the 
kidneys.     A  badly  placed  kidney  rest  annoys  the  surgeon, 
delays  the  operation,  and  possibly  cuts  off  the  patient's 
respirations,  while  the  anesthetic  nurse  gets  a  black  mark 

50 


THE   ANESTHETIC    NURSE  51 

in  anatomy.      If  the  patient's  arms  are  under  her  body 
paralysis  may  ensue. 

(3)  Sims  Position. — Always  to  be  used  in  giving  ene- 
mata  except  where  a  wound  prevents  it  (and  then  only 
with   the   doctor's   permission   to   do   differently).     The 
patient  lies  on  her  left  side,  her  left  knee  drawn  partly  up 
to  her  chin,  her  right  knee  farther  still — this  opens  up  the 
way  to  the  rectum  and  vagina.     The  hips  and  knees  must 
form  a  straight  line,  parallel  with  the  end  of  the  table,  and 
hanging  slightly  over  it.     A  real  Sims  table  has  an  ex- 
tension on  the  left  side  for  the  feet.     Her  left  arm  is 
gently  drawn  out  from  before  her  breast   and    placed 
behind  her,  at  the  right  of  the  table.     Her  chest  should  be 
flat  on  the  table   and  her  face  turned  to  one  side  com- 
fortably.    Her  right  arm  is  above  her  head. 

(4)  Lithotomy  Position. — The  patient  lies  flat  on  the 
table,  drawn  down  with  the  Kelly  pad    so   far  that  her 
buttocks  will  hang  over  the  end  when  the  foot  is  dropped. 
Each  foot  is  hung  up  in  a  stirrup  which  has  a  strap  hang- 
ing from  a  snap,  making  two  loops,  which  pass  (1)  up 
behind  the  heel  and  (2)  under  the  instep.     The  screws  of 
the  stirrups  work  simply  and  must  be  kept  well  oiled, 
but  they  must  be  practised  on  before  a  patient  reaches  the 
operating  suite.     It  is  very  wearing  on  a  surgeon's  temper 
to  have  to  ask  every  day  to  have  the  patient  "brought 
down  a  little  further."     The  stirrups  must  always  be 
kept  in  one  conspicuous  place. 

(5)  Knee-chest    Position. — The    patient    is   not   anes- 
thetized.    She  kneels  on  the  operating-table  as  near  the 
foot  as  possible  (for  cystoscopy,  etc.),  with  her  face  down 
on  the  table  and  her  breast  down  to  her  knees.      She  needs 
support  from  beneath  her  abdomen. 

(6)  Trendelenburg  Position. — When  a  patient  is  placed 
in  a  recumbent  position  for  a  gynecologic  operation  it  is 
well  to  expect  a  call  for  Trendelenburg.     Her  knees  must 
be  about  2  inches  below  the  joint  in  the  table,  so  that  when 
the  shelf  drops  the  bulk  of  her  calves  will  not  prevent  her 
knees  from  dropping  parallel  with  it.     Her  limbs  must  be 


52 


OPERATING   ROOM 


securely  pinned  in  a  warm  woolen  blanket   about   one 
yard  square,  brought  around  from  behind  them,  caught  up 


Fig.  5. — Gwathmey  gas-oxygen  apparatus. 

at  the  feet  into  a  pocket,  and  pinned  in  front.  Her 
shoulders  are  rested  against  two  shoulder  props  which 
must  always  be  newly  and  fatly  padded  to  prevent 


THE    ANESTHETIC    NURSE  53 

paralysis  of  the  trapezius  muscle.  The  modern  table  is 
wound  up  or  lowered  at  the  anesthetist's  will,  and  it  is 
positively  his  business  to  notify  the  operator  that  he 
must  lower  her  if  she  is  "going  bad."  But  the  nurse  her- 
self should  be  placed  in  Trendelenburg  by  the  super- 
visor, and  should  also  learn  all  the  mechanism  of  the 
table.  There  should  be  a  pad  for  the  table  of  rubber 
filled  with  air  and  hair,  and  with  boxed  edges,  to  pre- 
vent the  patient  from  rolling  off.  The  best  method  in 
any  operating  room  is  to  prepare  the  patient  on  the  table 
which  the  surgeon  will  use,  and  roll  her  in,  all  ready. 
This  avoids  lifting  her  once  when  anesthetized.  It  also 
prevents  any  of  the  customary  awkwardnesses  of  arrang- 
ing her  on  the  table  while  every  doctor  waits.  This  sys- 
tem, of  course,  requires  two  tables  of  the  same  kind  that 
are  used  in  any  special  operations,  but  anything  to  save 
time  is  a  gain. 

Setting  Up  the  Anesthetic  Room. — The  anesthetic 
nurse  sets  up  her  room  with  the  various  kinds  of  ap- 
paratus for  anesthesia,  the  inhalers  for  gas-ether,  gas- 
oxygen,  or  other  anesthetics  (Fig.  5),  the  tripods  for  gas 
tanks,  the  usual  sizes  of  face  masks,  cones,  or  masks  for 
chloroform  and  ether,  according  to  the  "drop"  method 
and  the  "open"  method,  vaselin  or  K-Y  for  the  patient's 
skin,  bandages,  and  means  for  restraint,  binders,  chest 
blankets,  large  blankets,  sheets,  cloth  stretchers  (i.  e., 
small  stout  double  sheet,  1|  yards  long  by  J  yard  wide,  of 
unbleached  muslin,  used  in  lifting),  chloroform,  ether, 
pins  (straight  and  safety),  a  jack-knife  to  open  ether  cans, 
pus-basins  with  a  high  wall  on  the  outer  side  to  prevent  a 
spray  of  vomitus,  towels,  sponges,  mouth-wipes,  two 
sponge  forceps,  tongue  clamp  (Fig.  6),  tongue  suture, 
mouth-gag  (oral  screw — Fig.  7 — of  black  rubber),  scratch 
pad  and  pencil,  wrist  watch  for  herself,  pocket  light, 
oxygen  tank  and  its  fixtures,  stomach-tube,  rubber  cap 
for  the  patient's  head  or  "ether"  cap  made  with  a  towel 
(Fig.  8),  bed-pan  and  urinal  for  nervous  patients  (with 
proper  covers  of  muslin),  special  unsterile  sheets  for  drap- 


54  OPERATING   ROOM 

ing,  triangles,  extra  large  towels  to  lie  between  the  tri- 
angles temporarily,  bandage  scissors,  pads  of  gauze  and 
cotton  fitted  to  the  eyes  and  bridge  of  the  nose  to  pre- 
vent "ether  eyes,"  and  lastly,  the  stimulation  tray. 

The  stimulation  tray  should  contain  only  the  drugs  used 
during  operations:  (1)  Morphin;  (2)  atropin;  (3)  strychnin; 

(4)   digitalin;   (5)  whisky;   (6) 
brandy;  (7)  camphor. 

These  are  excellently  pre- 
pared for  emergency  use  in  a 
form  called  the  Greeley  units, 
consisting  of  a  small  glass 
tube  containing  the  dose 
specified  on  a  legible  printed 
slip,  as  strychnin,  gr.  eV,  a 
needle  ready  for  injection, 


Fig.  6. — Tongue  clamp  with  soft-      Fig.  7. — Mouth-gag.   Oral  screw, 
rubber  tips.  hard  rubber  or  boxwood. 


but  protected  by  a  sterile  cover,  and  a  small  soft  metal 
collapsible  tube  (on  the  principle  of  a  cold  cream  tube) 
which,  when  squeezed,  forces  the  fluid  dose  through  the 
bared  needle.  There  should  be  a  large  assortment  of 
doses  of  each  of  these  on  hand.  The  drug,  camphor, 
should  always  be  kept  in  ampoules,  and  the  small  files 
coming  with  them  must  not  be  lost.  Their  contents  are 
more  easily  drawn  into  a  hypo,  syringe  from  a  sterile 


THE    ANESTHETIC    NURSE 


55 


spoon  than  from  the  ampoule  itself.  The  glass  of  the 
ampoule  must  not  be  broken.  The  speed  and  the  ac- 
curacy of  the  dose  are  two  potent  advantages  in  using 
ampoules  and  Greeley  units. 


••••MIMMBHHHHMHHHHHHMBBAaBi 

Fig.  8. — A  serviceable  "ether"  cap  for  all  purposes. 


The  anesthetist's  cap,  jacket,  and  trousers  are,  of 
course,  laid  out  in  the  dressing-room  used  by  the  surgeons, 
and  need  not  be  sterilized. 

To  produce  speed  in  work  there  should  be  on  the 
supply  table  of  the  anesthetic  room  a  standard  number 


56  OPERATING   ROOM 

of  articles  of  each  kind,  so  that  when  the  pile  is  reduced 
one  can  tell  at  a  glance  how  many  of  each  to  get  again. 
They  should  always  be  in  a  fixed  order  or  grouping,  so  as 
to  facilitate  their  instant  selection  by  all.  This  is  no 
place  for  a  nurse's  individual  whims.  When  a  valuable 
suggestion  can  be  made,  however,  there  is  a  correct  time 
to  do  it  and  a  correct  way,  that  is,  modestly,  when  the 
day's  work  is  done.  Otherwise  all  must  follow  the  same 
routine. 

When  the  patient  arrives  in  the  anesthetic  room  she  is 
asked  whether  she  has  any  false  teeth,  loose  teeth,  crowns, 
or  bridges  in  her  mouth,  any  hairpins,  false  hair,  jewelry, 
or  artificial  parts,  which  all  interfere  with  her  own  phys- 
ical safety  under  anesthesia.  The  wedding  ring  may  be 
tied  on  with  J-inch  tape,  one  knot  in  the  ring,  one  double 
knot  at  the  back  of  the  wrist,  and  another  below  the 
palm. 

Patients  may  desire  to  void  urine  again,  through 
nervousness  or  long  delays,  and  it  cannot  be  reiterated 
too  loudly  or  too  often  that  a  full  bladder  is  a  very  danger- 
ous condition  under  the  knife.  Free  urine  in  the  ab- 
domen acts-  as  a  highly  poisonous  foreign  body,  the 
patient  sometimes  dying  from  absorption,  while,  on  the 
other  hand,  the  bladder  walls  heal  slowly. 

It  is  a  solemn  thing  to  a  whole  family  when  a  patient 
takes  an  anesthetic.  What  nurse  covets  the  opportunity? 
Put  yourself  in  the  patient's  place.  Do  not  talk  while 
she  is  going  under.  The  best  anesthetic  nurse  will 
have  a  certain  calm  assurance,  kindness,  and  dignified 
cheeriness  that  must  be  worn  at  all  times,  even  when  the 
operation  will  possibly  prove  fatal.  The  anesthetic  nurse 
may  be  the  last  person  the  patient  will  ever  see  or  the 
last  one  to  whom  she  will  speak.  To  the  patient  herself 
and  to  the  family  loss  of  consciousness  is  the  big  thing, 
not  the  operation  at  all.  Most  of  us  dread  the  conse- 
quent helplessness,  and  would  bravely  endure  any  pain 
to  be  allowed  to  know  what  was  going  on.  The  frequency 
of  assisting  and  the  almost  universal  success  of  all  the 


THE    ANESTHETIC    NURSE  57 

cases  must  not  make  a  nurse  treat  them  lightly,  not  even 
a  child.  It  is  a  well-known  fact  that  doctors  and  nurses 
are  the  worst  sort  of  patients. 

The  gown  must  be  loosened  at  the  neck  to  permit  dis- 
tention  of  the  blood-vessels  during  the  period  of  excite- 
ment. The  noise  made  by  filling  the  gas-bag  in  the  gas- 
ether  apparatus  should  be  got  over  with  before  the  pa- 
tient's eyes  are  covered.  No  delay  is  permissible  after 
that.  By  good  careful  inspection  of  the  apparatus 
leaks,  etc.,  are  detected.  There  should  always  be  a  reserve 
stock  of  ether  and  gas-bags  with  other  rubber  goods  kept 
in  a  cool  place  in  lycopodium  or  other  powder.  The 
patient  must  not  be  left  alone  for  one  moment  from  the 
time  of  her  arrival  in  the  anesthetic  room. 

The  orderly  who  brings  up  the  stretcher  should  disap- 
pear at  once.  He  should  not  be  seen  by  the  women 
patients  afterward.  It  makes  them  fear  that  he  will  be 
present  during  the  operation,  where,  of  course,  he  is  never 
allowed.  He  may  be  called  to  assist  in  lifting  the  patient, 
though  that  is  not  necessary  when  she  is  anesthetized  on 
the  operating-table.  Forethought  and  good  executive 
ability  are  required  to  think  out  and  define  the  detailed 
duties  of  each  member  of  the  company  before,  the  play 
begins. 

The  nurse  may  have  to  bestow  sundry  petty  attentions 
on  the  anesthetist,  especially  if  he  be  a  stranger,  but  they 
are  minimized  by  having  everything  in  order  on  the 
supply  tables.  A  good  anesthetist  will  try  to  deflect  the 
nurse's  attention  entirely  to  the  patient  and  find  what  he 
needs  before  beginning  the  anesthetic. 

In  transferring  from  the  operating-table  to  the  stretcher 
(1)  the  anesthetist  lifts  the  head  and  shoulders;  (2)  the 
anesthetic  nurse  and  the  orderly  the  middle  of  the  body 
by  means  of  the  small  stretcher  sheet;  (3)  the  operating- 
room  "dirty  nurse"  the  feet. 

Similarly,  in  putting  the  patient  to  bed,  these  rules  hold, 
except  that  the  receiving  nurse  takes  the  feet.  It  is 
wisest  to  have  no  stretcher  for  special  cases — run  the  oper- 


58  OPERATING   ROOM 

ating-table  to  their  bedside  and  take  them  upstairs  on  it. 
Again,  some  common  cases  of  appendicitis,  etc.,  are 
lodged  in  the  bodies  of  highly  nervous  people,  who  wish 
to  be  anesthetized  in  the  operating  room,  where  they  may 
face  the 'worst.  Let  them  have  their  way.  Where  an 
anesthetist  ungallantly  shirks  in  his  share  of  the  lifting, 
imperilling  his  patient's  respirations,  the  operating 
surgeon  should  reprimand  him.  If  he  does  not  see  it, 
the  supervisor  should  report  him.  Lifting  at  a  higher 
level  than  the  point  of  one's  greatest  strength  is  not 
necessary  or  conducive  to  good  health  in  women.  Unison 
should  prevail  in  points  like  these,  but  the  supervisor 
should  be  granted  especial  authority  to  note  and  mention 
details  of  this  sort,  to  "break  in"  new  men,  tactfully,  of 
course,  and  always  on  the  basis  of  the  patient's  best  in- 
terests. The  anesthetist  counts  "one,  two,  three!"  and 
on  "three"  everyone  lifts. 

The  arms  require  especial  care  at  all  times.  In  transit 
on  a  stretcher,  they  should  be  pinned  on  the  chest  and 
kept  in  place  by  the  blanket,  always  brought  up  from 
beneath.  In  the  dorsal  and  recumbent  positions  they  are 
(1)  placed  parallel  with  the  body,  or  (2)  brought  up  above 
the  head. 

Problem  of  Nurses  Giving  Anesthetic. — Some  nurses 
try  to  get  as  far  away  from  nursing  as  possible  after 
receiving  their  diploma.  Among  these  are  some  "nurse 
anesthetists."  The  pupil  "anesthetic  nurse"  watches  the 
pulse  for  her  own  information  only,  but  when  asked  what 
it  is,  should  state  the  truth.  Nurses  never  dissect  nor 
vivisect,  and  cannot  tell  the  deeper  actions  and  reactions 
of  chloroform  or  ether.  It  seems  absurd,  therefore,  and 
dangerous  too  to  qualify  them  as  anesthetists  and  en- 
trust them  with  lives  to  just  as  great  a  degree  as  the  man 
with  the  scalpel.  If  a  "nurse  anesthetist"  finds  a  pa- 
tient "going  bad"  she  cannot  legally  prescribe  a  hypo- 
dermic or  an  infusion.  It  is  true  that  she  may  have  a 
quicker  intuition  and  sympathy  with  the  patient,  but  this 
cannot  be  charted  or  justified  in  a  court.  Then,  again, 


THE    ANESTHETIC    NURSE  59 

what  counts  for  more,  she  works  for  a  low  salary,  much 
less  than  a  physician's,  and  she  cannot  take  any  ana- 
tomic interest  in  the  surgical  procedure  to  distract  her 
attention.  But  these  factors  cannot  conscientiously 
atone  for  the  dangers  she  creates  by  her  ignorance.  If  a 
patient  dies  under  an  anesthetic  given  by  a  physician 
the  relatives  accept  the  situation  philosophically,  not 
dreaming  to  dispute  his  skill,  but  if  in  a  nurse  anesthetist's 
hands,  what  then?  Then,  too,  nurses  should  not  lend 
themselves  to  the  exploitation  of  human  flesh,  unpardon- 
able in  any  profession.  A  corporation  should  not  make 
an  ill-proportioned  profit  out  of  the  services  of  any  skilled 
employee.  If  a  nurse  anesthetist  gives  ten  anesthetics 
per  day  at  $10  each,  and  receives  a  salary  of  $60  per 
month,  she  is  exploited  like  a  slave,  and,  worse  still,  she 
helps  the  system  along. 

As  soon  as  one  case  is  well  begun  the  anesthetic  nurse 
arranges  the  stretcher  and  leaves.  There  should  always 
be  a  binder  of  proper  size  on  it  for  abdominal  cases,  so 
that  they  may  be  rubbed  clean  and  dry,  and  lifted  to  the 
stretcher  to  be  finished  up.  To  facilitate  putting  on  the 
binder  rows  of  safety-pins  are  kept  in  Castile  soap. 

In  odd  minutes,  waiting  for  an  anesthetist,  .the  nurse, 
if  industrious,  should  make  hundreds  of  yards  of  packing 
(Fig.  9).  Before  she  is  called  to  the  third  service,  of 
"scrubbed  nurse,"  she  talks  with  the  senior  as  they  clean 
instruments  together  after  cases,  discussing  how  many  of 
each  and  why  all  were  used,  or  may  help  clean  instru- 
ments so  as  to  send  them  away  with  their  owner  after  his 
case  is  over. 

Oxygen  may  be  conveniently  handled  in  small  tanks 
that  can  be  lifted  in  one  hand,  or  stand  on  a  low 
tripod,  like  the  nitrous  oxid  tanks.  The  large  oxygen 
tanks  can  be  rolled  from  place  to  place,  first  removing  the 
fixtures.  To  administer  oxygen  properly  is  not  difficult, 
but  it  is  a  source  of  many  mistakes.  A  gauge  can  be 
bought  at  any  first-class  instrument  maker's,  and  by  un- 
screwing the  nozzle  for  the  fixtures,  this  may  be  screwed 


60 


OPERATING    ROOM 


on.  It  is  a  dial,  which  when  opened  shows  at  once  how 
many  pounds'  pressure  remain  in  the  tank.  All  oxygen 
tanks  in  the  hospital  should  be  regularly  tested,  and  there 


Fig.  9. — Making  packing  from  a  bandage. 

should  always  be  one  or  more  full  tanks  in  reserve,  ac- 
cording to  the  number  of  beds.  The  oxygen  weighs  next 
to  nothing.  One  cannot  tell  by  any  means  but  the  gauge 
whether  a  tank  is  full  or  empty  without  wasting  it. 


THE   ANESTHETIC    NURSE  61 

But  it  is  expansive  to  the  pushing  strength  of  250  pounds 
in  the  largest  size  of  tanks  provided  for  hospital  con- 
sumption. On  the  tank  hangs  a  bottle  of  clear  glass  con- 
taining clean  water  always  fresh.  Through  the  rubber 
cork  go  two  bent  glass  tubes.  The  tube  running  down  the 
lower  must  be  under  water.  It  is  connected  with  the 
tank,  and  the  oxygen  must  be  forced  into  the  water  for 
three  reasons:  (1)  It  detects  a  leak;  (2)  it  moistens  the 
oxygen  and  renders  it  fit  to  breathe;  (3)  it  helps  us  regu- 
late the  flow — it  should  be  given  at  the  rate  of  three 
bubbles  showing. 

The  shorter  glass  tube  is  connected  with  the  patient. 
If  this  is  reversed,  the  water  will  be  blown  all  over  the 
place  and  the  oxygen  wasted.  By  using  the  gauge  before 
and  after,  on  certain  cases,  the  amount  used  can  be 
estimated  and  charged  for  at  the  hospital  cost  of  1  cent 
per  pound.  In  ordering  oxygen  be  sure  to  state  that  it 
must  be  odorless.  If  stored  in  stables  it  is  very  un- 
pleasant. The  distance  of  the  factory  from  the  hospital 
is  a  factor  determining  how  soon  to  order  again. 

A  small  catheter  well-lubricated  except  in  the  eye,  or 
specially  made  flat  nose-pieces  of  black  rubber  are  best 
for  ordinary  stimulation,  the  funnel  method  having  gone 
into  disfavor.  A  lighted  match  shows  that  by  the  funnel 
method  the  oxygen  ascends  to  the  ceiling. 

All  oxygen  face  fixtures  must  be  boiled  and  sunned 
after  using,  since  in  many  cases  they  were  used  for  lung 
diseases.  The  pneumococcus  or  tubercle  bacillus  could 
be  thus  directly  transmitted  if  no  prophylaxis  were  ob- 
served. 

After  the  Operation. — The  anesthetic  nurse  accompanies 
the  patient  to  her  bed,  and  goes  over  her  thoroughly  with 
the  ward  nurses  to  show  that  she  has  delivered  her  to 
them  in  good  condition.  She  collects  all  her  basins, 
blankets,  etc.,  and  returns  to  the  operating  room  at  once, 
to  boil  all  masks,  pus-basins,  etc.,  before  using  them  for 
another  case. 

The  chart  accompanies  the  patient  downstairs,  with 


62  OPERATING   BOOM 

a  slip  fastened  to  it  containing  the  important  details  of 
the  operation.  It  may  be  used  for  reference  during  the 
case.  If  the  patient  has  not  voided  before  the  anes- 
thetic, this  is  reported  to  the  surgeon  by  the  anesthetic  nurse, 
since  she  was  the  last  one  to  converse  with  the  ward 
nurse.  It  may  be  on  the  chart,  but  it  must  be  verbally 
reported. 

Tonsil  cases  are  laid  face  downward  on  the  stretcher 
when  being  taken  to  bed,  with  their  arms  above  their 
head  and  their  faces  slightly  turned  for  air,  in  order  to 
swallow  no  blood. 

Some  very  skilful  surgeons  keep  drainage  appendix 
cases  on  their  face  also,  and  the  results  are  good. 

The  anesthetic  nurse  has  several  true  nursing  duties 
while  in  charge  of  her  patient: 

(1)  She  must  keep  him  warmly  covered,  bringing  up 
one  blanket  from  below  his  body,  then  covering  him  with 
a  head  cover  and  a  chest  blanket,  pinning  his  neck  closely 
so  that  no  air  will  get  in  while  his  pores  are  opened  with 
ether,  and  pinning  his  sleeves  to  his  chest  to  prevent  frac- 
tures while  in  transit  or  being  lifted  to  bed. 

(2)  She  watches  for  hemorrhages  and  vomiting. 

(3)  She  sees  that  the  bed  is  clean,  warm,  and  dry,  and 
that  there  are  no  hot-water  bottles  anywhere  in  it;  also 
that  the  rubber  drawsheet  was  not  superheated  by  them, 
to  burn  him. 

(4)  She  learns  how  to  hold  the  jaws  to  prevent  a  pa- 
tient from  swallowing  his  tongue,  downward  and  back — 
practising  on  the  class  skeleton. 

(5)  She  learns  to  sponge  out  mucus. 

(6)  She   administers   amyl   nitrite — now    prepared   in 
dainty  silk  and  lint  covered  tubes  all  ready  to  crush,  the 
lint  absorbing  it,  instead  of  the  piece  of  gauze  that  was 
never  at  hand — the  old-fashioned  pearl  was  crushed  in  a 
piece  of  gauze  by  a  firm  hand  or  a  weight,  and  held  a  few 
inches  from  the  patient's  face. 

(7)  She  learns  how  to  do  artificial  respiration  slowly 
enough — 16  strokes  to  the  minute. 


THE    ANESTHETIC    NURSE  63 

(8)  She  prevents  burns  by  the  use  of  a  face  lubricant, 
a  hospital  cold  cream  preferably. 

Special  anesthetics  require  a  note  here.  Spinal  anes- 
thesia, a  fascinating  experiment,  is  seldom  used,  but  has 
its  special  outfit.  This  is  performed  with  the  strictest 
asepsis,  if  such  can  be,  on  account  of  tapping  the  cord 
and  putting  germs  in  possibly  with  the  anesthetic.  The 
Medical  Board  should  render  decisions  about  anesthetics 
to  be  purchased  and  prepared  by  the  hospital  and  its 
staff  for  ward  cases,  but  for  private  cases  each  surgeon 
will  be  allowed  his  choice,  within  reason,  at  his  patient's 
expense.  Fads  must  be  kept  out.  The  good  name  of 
the  hospital  is  in  the  trust  of  the  Medical  Board.  An 
error  of  any  sort  in  the  choice  of  anesthetic  should  lead 
to  a  searching  trial. 

In  rectal  anesthesia  the  nurse's  duties  are  prominent. 
She  gives  the  enema — olive  oil,  5vj;  ether,  5ij — mixed  in 
an  enamel  graduate  with  a  funnel,  rubber  tube,  glass 
connecting  tube,  large  male  catheter  lubricated,  and  an 
artery  clamp,  all  these  articles  standing  in  a  neat  basin 
with  a  covering.  The  patient's  face  is  covered,  so  that 
he  rebreathes  what  his  lungs  eliminate.  Then,  after  the 
operation  is  complete,  the  amount  not  yet  absorbed  is 
siphoned  off  with  a  larger  tube  (rectal)  and  the  bowel 
flushed  with  cool  water  and  soapsuds.  One  ounce  of 
ether  and  three  of  oil  are  used  for  every  75  pounds  of 
body  weight. 

Chloroform  and  ether  deteriorate  if  exposed  to  air, 
and  must  be  bought  in  containers  as  small  as  possible — 
ether,  in  J-pound  cans;  chloroform,  40  grams.  In  be- 
ginning a  new  case  an  anesthetist  must  open  a  new  bottle. 
To  carry  it  on,  most  men  will  use  the  left  overs  from  a 
previous  case.  If  not,  use  these  ends  for  cleaning,  keep- 
ing them  in  two  stock  jars.  It  is  especially  good  for 
grease  marks.  Chloroform,  ether,  and  ethyl  chlorid  must 
not  be  allowed  to  evaporate.  That  is  wasteful.  Chloro- 
form masks  may  be  covered  with  flannel,  which  is  boiled 
after  every  case,  thus  getting  so  hard  that  it  must  be  fre- 


64 


OPERATING   ROOM 


quently  renewed.     Anything  more  open  of  mesh  will  let 
drops  through. 

The  pulmotor  (Fig.  10)  requires  skilled  care  in  cleaning, 
especially  in  not  confusing  the  parts  and  closing  off 
the  wrong  channels,  but  can  be  operated  by  anyone. 


Fig.  10. — The  pulmotor.  For  resuscitation  of  the  apparently 
lifeless  from  the  effects  of  anesthesia,  poisonous  gases,  smoke,  drown- 
ing, electricity,  collapse  from  any  cause.  The  operator  applies  a 
face  mask  and  turns  a  key,  starting  the  mechanism  of  the  apparatus, 
to  produce  immediate  and  measured  respiration,  with  pure  oxygen 
entering  the  lungs  at  each  inhalation.  The  tongue  is  held  forward 
by  forceps,  and  oxygen  prevented  from  entering  the  esophagus  by 
pressure  with  the  right  hand  (Da  Costa,  Modern  Surgery). 

All  syringes,  as  for  spinal  anesthesia,  must  be  very 
thoroughly  cleansed  with  cold  water  after  containing 
human  serum,  which,  if  cooked,  will  ruin  their  working. 

Pus-basins  for  vomit  us  should  have  a  high  outer  wall. 

The  anesthetist  should  have  a  certain  position  for  his 
table  of  supplies.  When  the  nurse  is  coming  in  with  the 
patient  the  orderly  may  carry  this  table  to  its  place  and 
provide  him  with  his  high  stool. 


THE    ANESTHETIC    NURSE  65 

The  anesthetist  is  sometimes  covered  by  a  sheet, 
and  must  be  especially  assisted  in  small  ways.  When 
holding  a  child  for  staphylorrhaphy  the  nurse  is  also 
covered  with  a  sheet,  and  should  get  some  special  atten- 
tions, since  nothing  is  to  be  gained  by  smothering  her  in 
her  own  CO2.  A  harelip  infant  recovers  more  smoothly 
the  sooner  it  is  operated  on,  and  is  held  with  its  arms 
pinioned  in  a  small  towel  up  against  the  nurse's  breast 
and  neck. 

To  pin  up  a  child,  use  a  large  face  towel,  or  a  small 
double  muslin  sheet  made  for  such  purposes.  Lay  the 
towel  about  its  hips,  the  long  edge  horizontal,  and  pin 
once  in  front.  Pin  the  child's  cuffs  together  over  its 
stomach,  thus  folding  its  arms  down.  Reverse  the  towel, 
so  that  it  rises  toward  the  head.  Pin  straight  up  the 
front.  Then  make  darts  of  equal  size  on  the  shoulders. 

5 


CHAPTER  IV 

THE  SCRUBBED  NURSE 

THIS  nurse  has  fewer  duties  assigned  her,  but  requir- 
ing much  skill,  physical  endurance,  patience,  and  the 
crystallizing  of  all  she  has  previously  learned  to  focus  it 
on  this  particular  case.  A  nurse  in  this  position  must 
keep  good  hours,  wear  sensible  shoes,  and  conserve  her 
energy  so  as  to  have  a  clear  head  and  not  give  the  wrong 
kind  of  needles  or  sutures.  To  save  time  the  "dirty 
nurse"  may  cleanse  the  tables  with  carbolic  acid  solution 
(5  per  cent.)  and  unpin  all  the  packages  to  be  used  in  setting 
up,  while  the  senior  puts  on  her  cap  and  scrubs  to  set  up, 
finally  donning  gloves  and,  as  some  insist,  a  gown.  She 
spreads  the  covers  on  the  tables,  so  that  the  part  going 
over  the  edges  is  the  last  she  touches,  being  pushed  from 
her.  She  stands  as  far  as  possible  from  the  table,  so  as 
not  to  let  her  gown,  bib,  or  apron  come  in  contact  with  it. 
Having  set  all  her  basins,  etc.,  in  order,  she  removes  her 
gloves,  scrubs  again,  dons  her  clean  gown  and  new  gloves. 

The  junior  brings  her  the  tray  of  boiled  instruments, 
held  away  out  before  her,  the  senior  using  every  such 
opportunity  to  teach  her  asepsis.  The  instruments  should 
always  be  disposed  on  the  table  in  a  routine  way,  so  that 
one  may  pick  up  a  clamp  without  looking  to  bite  a 
spurter. 

Routine  is  not  always  to  be  adhered  to,  however,  be- 
cause it  kills  originality.  The  scrubbed  nurse  fastens 
the  first  four  towels  in  place  with  towel  clamps  for  the 
skin  preparation,  handing  the  assistant  a  sponge  stick  and 
a  glass  of  iodin,  followed  by  alcohol,  which  she  does  not 
receive  back.  She  again  fastens  a  set  of  towels  around  the 


THE    SCRUBBED    NURSE  67 

operative  area,  is  assisted  in  placing  the  laparotomy  sheet, 
and  over  it  places  four  towels  again,  laying  them  on  up- 
side down,  clamping  at  the  upper  edges,  and  then  pulling 
them  over,  right  side  up,  so  that  the  towel  clamps  will 
not  get  mixed  up  with  the  operating  instruments.  She 
puts  the  scalpel,  sponges,  artery  clamps,  and  mouse- 
tooth  forceps  on  the  towel,  then  swings  her  small  instru- 
ment table  into  position,  and  the  case  begins.  She  washes 
blood  off  all  instruments,  keeps  a  supply  of  wipes  and 
sponges,  offers  hot  saline  on  tape  sponges  when  the  intes- 
tine is  exposed,  not  after,  offers  ligatures,  sutures,  etc., 
noting  all  her  mistakes  (and  vowing  that  they  won't  recur) 
until  the  case  is  completed.  She  must  know  the  laws  of 
ligatures  and  sutures,  needles  and  instruments  (a)  from  her 
text-book  in  anatomy;  (6)  from  the  book  of  house  rules; 
(c)  from  the  surgeon's  own  words;  (d)  from  the  text-books 
on  operating-room  work. 

Sutures. — The  surgeons  will  frown  on  extravagance 
as  a  bad  omen  for  the  pupil's  private  work  in  future, 
besides  for  their  patient's  bill,  since  the  scrubbed  nurse 
is  supposed  to  count  the  amount  she  uses  and  charge  it  to 
the  case  in  some  institutions.  The  nurse  must  calculate 
it  to  an  inch,  and  report  all  data,  so  as  to  enable  the  hos- 
pital to  buy  closely,  so  many  short  lengths  of  each  kind, 
etc. 

Long-handled  Needles. — A  special  long-handled  needle 
has  recently  been  invented  to  sew  up  a  hemorrhagic  area 
after  tonsillectomy. 

Small  Needles. — Thread  them  quickly.  Cut  catgut  with 
a  bias  end,  and  know  the  needles,  whether  they  have  the  eye 
at  the  side  or  back.  Twist  the  thread  on  itself  once  or 
twice  at  the  eye,  after  threading,  and  it  will  lie  flat,  place 
in  the  needle-holder  one-third  from  the  eye,  the  point 
projecting  to  the  left  for  a  right-handed  surgeon,  and 
hand  to  him  with  one  bend  of  the  wrist,  throwing  the 
handle  into  his  palm,  the  mouth  pointing  back  to  the 
nurse,  who  catches  the  flying  thread  in  her  second  and 
third  fingers  to  keep  it  taut.  As  to  shapes  and  their 


68  OPERATING   ROOM 

uses,  the  head  nurse  makes  up  a  sample  card  for  in- 
struction. 

Needles  for  syringes  should  be  slip-ons,  since  they  are 
clean  and  easily  worked.  They  must  always  have  a 
stylet.  Special  needles  for  lumbar  puncture  have  an 
eye,  and  the  point  of  the  stylet  is  bevelled. 

Knives  are  right  and  left  for  throat  work.  If  the  edge 
has  a  full  curve  it  is  said  to  "belly."  Blades  set  in  a  frame 
— e.  g.,  the  tonsillotome — come  under  the  classification  of 
knives  in  their  care.  A  paracentesis  knife  for  myrin- 
gotomy  must  have  two  blades,  and  go  through  the  small 
end  of  any  ear  speculum. 

Ligatures. — These  are  chosen  according  to  the  size  and 
toughness  of  the  part,  their  time  for  absorption,  and  the 
size  and  importance  of  the  blood-vessels  involved.  They 
must  be  cut  long  enough  for  each  and  every  operator  to 
hold  in  a  firm  grip — i.  e.,  9  inches. 

Scissors  are  selected  with  a  view  to  the  anatomy  of  the 
part  and  the  operator's  hand.  They  are  blunt  or  sharp 
pointed,  straight  or  curved,  curved  on  the  flat  (right  or 
left),  or  curved  upward,  long  or  short. 

Forceps  are  straight  or  with  handles,  plain  or  with 
mouse  teeth,  pivot,  screw-lock  or  mortise-lock,  corru- 
gated or  smooth,  corrugated  crosswise  or  lengthwise, 
straight,  angular  or  specially  curved,  and  of  varying 
lengths.  There  are  also  special  kinds  of  forceps:  (a) 
placenta,  (6)  obstetric,  (c)  gastro-enterostomy,  (d)  gall- 
stone, etc.  An  artery  clamp  has  such  an  important  duty 
that  it  should  never  break,  and  the  inferior  molded  forceps, 
though  cheap,  must  give  way  to  the  superior  though  ex- 
pensive "drop-forged"  forceps. 

Instruments  generally  should  be  known  by  their  pur- 
pose, not  by  the  inventor's  or  maker's  name.  They  are 
chosen  for  operation  according  to  its  location,  the  depth 
of  the  wound,  and  the  shape,  size,  and  weight  of  the  organs 
involved.  Even  then  many  must  be  covered  with 
rubber  tubing  or  buttons  of  soft  rubber  in  order  not  to 
crush  a  delicate  part — e.  g.}  the  intestines. 


THE    SCRUBBED    NURSE  69 

Operators  have  many  idiosyncrasies  which  must  be 
mastered  and  noted  in  the  book  of  house  rules,  as  to  what 
position  best  suits  them,  the  height  of  the  table,  the  sort 
of  gloves,  whether  they  are  left-handed,  or  have  lost  a 
finger,  etc.  An  old-fashioned  table  can  be  heightened  by 
setting  it  in  four  pieces  of  iron  gas-pipe  of  equal  length, 
below  which  again  are  the  casters. 

Instructions  in  Conducting  an  Operating  Room. — 
The  scrubbed  nurse  receives  her  instruction  in  buying 
by  visiting  the  office  with  the  supervisor  when  she  makes 
her  weekly  requisitions,  as  well  as  by  discussing  costs, 
materials,  and  makes  while  at  work.  On  the  spindle  in 
the  workroom  is  placed  every  item  of  goods  running 
short,  goods  criticised  by  the  operators,  instruments  they 
asked  for,  or  anything  else  relating  to  the  work  of  oper- 
ating. 

She  collects  all  instruments  for  repair,  sharpening  or 
renickelling,  under  the  supervisor's  approval,  and  packs 
them  for  mailing,  knives  in  their  boxes,  padded  with  the 
cheapest  cotton,  scissors  rolled  in  the  soft  paper  which 
came  the  week  before,  and  all  listed  as  to  size,  shape,  and 
needs.  One  slip  goes  with  them  and  one  is  kept  in  the 
main  office,  but  the  original  list  is  made  in  the  book  for 
repair  of  instruments  which  is  not  destroyed,  since  it 
shows  how  certain  kinds  stand  wear,  while  others  may  have 
to  go  too  often  to  the  repair  shop,  etc.  The  Instrument 
Committee  is  chosen  from  the  surgeons,  and  they  have 
control  of  the  buying.  Under  the  supervisor's  direction 
she  visits  the  wards,  examines  their  instruments,  ships 
them  for  repair,  but  never  sends  the  only  two  of  one  kind 
at  one  time,  and  carefully  decides  about  what  to  discard 
permanently.  She  takes  all  the  night  operations  in  some 
hospitals  where  the  night  force  does  not  contain  a  nurse 
who  "has  had  operating  room."  The  supervisor  should 
not  have  to  take  night  cases,  since  it  is  most  essential 
that  she  should  have  a  clear  mind  and  a  rested  body  at 
all  times.  This  induces  the  capable  women  to  retain  these 
positions.  There  should  not  be  such  a  great  disad- 


70  OPERATING   ROOM 

vantage  created  in  any  one  sort  of  position.  The  pupil 
may  also  relieve  the  supervisor  for  her  time  off.  When  it 
comes  to  vacations,  the  selection  of  a  relief  nurse  comes 
before  the  hospital  staff.  She  should  be  one  acceptable 
to  all  branches  of  the  service. 

A  little  dissection  of  animals,  fowl,  and  fish  in  the 
main  kitchen  under  the  direction  of  the  dietetian 
makes  a  useful  complement  to  this  service  for  the 
scrubbed  nurse,  and  proves  just  as  interesting  as  it  is 
useful. 

The  scrubbed  nurse  has  charge  of  the  plaster  work, 
which  is  discussed  in  another  chapter.  She  also  looks 
after  the  cutting  of  gauze,  rolling  bandages,  making 
dressing-covers,  and  the  general  work  of  getting  sup- 
plies, watching  three  things:  (1)  the  every-day  supply, 
sterilized  and  circulating;  (2)  a  reserve  of  sterilized  goods, 
always  kept  up  to  a  fixed,  written  standard;  (3)  a  HUGE 
unsterile  reserve  of  made-up  goods,  cotton,  gauze,  and 
muslin  covers,  so  that  there  may  always  be  plenty,  no 
matter  whether  there  be  (a)  a  breakdown  in  the  sterilizers; 
(6)  an  unusually  large  number  of  operating  and  pus  cases; 
(c)  or  some  epidemic  among  the  nurses. 

The  scrubbed  nurse  sharpens  her  commoner  instru- 
ments with  strop  and  hone,  or  oil  stone.  She  tests  all 
instruments  for  sharpness,  rust,  bite  or  spring,  making 
a  drumhead  out  of  the  wrist  of  an  old  glove  over  an 
embroidery  hoop  for  edges.  If  it  cuts  smoothly,  the 
knife  is  sharp;  if  it  is  uneven,  the  knife  is  dull. 

Business. — All  parcels  bear  addresses,  which  should  be 
carefully  noted  and  memorized.  Catalogs  of  the  leading 
firms  amply  afford  interesting  and  instructive  study 
material  through  their  illustrations. 

Ambulance  bags  should  be  under  the  control  of  the 
operating  room  (unless  the  ambulance  room  has  its  own 
graduate  nurse)  so  as  to  unify  the  supplies,  especially  of 
instruments.  The  bag  should  be  sent  up  by  the  intern 
who  rides  the  ambulance  each  time  anything  is  used  in 
it,  instantly  replenished,  and  instantly  returned.  The 


THE    SCRUBBED    NURSE  71 

special  emergency  goods  for  it  are  tourniquet,  cord  tape, 
cord  instruments,  mouth-gag,  hypodermic  set,  packing, 
and  small  oxygen  tanks.  Here  again  is  registered  a  pro- 
test against  hospitals  making  their  own  catgut,  since  it 
has  nothing  whatever  to  do  with  a  nurse's  private  duty. 
General  Hints. — 1.  Be  sure  to  lubricate  vaginal  or 
rectal  specula. 

2.  All  thick  heavy  instruments  must  be  thoroughly 
cooled  in  a  deep  basin  of  sterile  water. 

3.  The  scrubbed  nurse  must  be  ready  to  assist  at  the 
wound  when  called. 

4.  Slides,  smear-glasses,  etc.,  for  specimens  are  kept 
in  their  own  basin,  apart. 

5.  Applicators  must  be  wound  correctly — 

(a)  So  as  to  be  fluffy  at  the  end. 

(6)  So  as  to  come  apart  easily. 

(c)  Cleansed  by  a  second  piece  of  cotton. 

(d)  So  as  to  bury  the  end  of  the  instrument  so 

that  it  cannot  inflict  a  wound. 

6.  Silk-gut  sutures  must  never  be  buried. 

7.  Improvise  a  weighted  speculum  with  a  pail  of  water 
(quart)  on  the  Sims. 

8.  Do  not  carry  bundles   of   sterile   goods  near  the 
body,  better  use  a  tray. 

9.  Practice  taking  the  wires  out  of  a  tonsil  snare. 

10.  If  the  nurse  is  left  handed,  she  must  correct  that 
in  passing  instruments  to  a  right-handed  man. 

11.  She    must    instantly    recognize    the    instruments 
owned  by  each  surgeon  on  the  staff— 

(a)  By  the  make. 
(&)  Shape. 

(c)  Age  and  condition. 

(d)  Numbers  on  the  parts. 

12.  Note  the  numbers  on  all  clamps,  knives,  etc. 

13.  Use  instruments  to  work  with,  at  the  sterile  table. 

14.  When  the  surgeon  says,  ' 'There  is  one  sponge  in  the 
vagina,"  don't  let  him  forget  it. 

15.  Wash  the  patient,  dry  her,  and  rub  with  alcohol 


72  OPERATING    ROOM 

• 

and  powder,  looking  for  burns  from  iodin,  bruises,  etc., 
before  applying  the  binder. 

16.  See  that  the  dirty  nurse  puts  the  binders  on  well, 
and  have  plenty  of  them,  properly  made. 

17.  Large  abdominal  retractors  must  be  warmed  to 
100°  F.  to  prevent  shock. 

18.  Hand  solutions  that  are  too  hot  burn  the  doctor's 
hands  and  delay  the  operation. 

19.  Irrigating  solutions  must  have  an  infusion  ther- 
mometer inclosed  in  a  connecting  tube  to  show  their 
temperature. 

20.  Chloroform  seals  rubber  tissue  for  a  neat  skin  dress- 
ing. 

21.  Have  very,  many  clamps  for  breast  amputations 
and  vaginal  hysterectomies, 

22.  If  called  to  sponge,  press  once  deeply  on  the  bleed- 
ing area  (except  the  eye,  an  ulcer,  or  an  appendix  about 
to  rupture)  until  the  surgeon's  hand  approaches,  then  lift 
quickly. 

23.  Keep  a  generous  stock  of  all  sizes  of  sand-bags. 

24.  Keep  a  number  of  Politzer  bags  and  plenty  of  rubber 
dam  for  cholecystectomy  and  rib  resection  for  drainage 
by  suction. 

25.  When  aristol  is  shaken  over  a  wound,  see  that  the 
dirty  nurse  does  so,  with  a  wet  bichlorid  towel  around  the 
shaker  and  her  own  wrist. 

26.  When  a  Murphy  button  has  been  used  for  intes- 
tinal anastomosis,  a  very  special  notice  must  be  issued  by 
the  scrubbed  nurse  to  the  ward  nurses,  and  the  "button" 
should  be  the  subject  of  general  comment  until  it  is 
found  (Fig.  11). 

27.  All  pus,  etc.,  must  be  confined  to  the  towels  on 
which  it  fell,  and  passed  on  .to  the  other  nurse  to  be  disin- 
fected.    An  effort  is  made  to  keep  all  dirt  in  as  narrow  a 
space  as  possible,  and  to  make  it  harmless  AT  ONCE  by  dis- 
infection. 

28.  Needles    should    be    boiled    in    perforated    metal 
(nickel)   boxes   (about  4  x  2  x  1J  inches)   for  safety  as 


THE    SCRUBBED    NURSE  73 

to  number,  care  of  the  points,  -and  the  nurse's  finger- 
tips. 

29.  Loose  silk  may  be  drawn  into  gauze  before  boiling. 

30.  Needles  may  be  threaded  with  silk  and  drawn  into 
gauze  before  boiling,  or  dry  sterilized  in  flannel. 

31.  A  man  run  over  by  an  auto  is  a  clean  case,  and  yet, 
off  the  street,  may  have  received  the  tetanus  germ  into 
his  blood.     At  the  first  hint  from  the  surgeon,  the  scrubbed 
nurse,  listening  intently,  passes  the  suggestion  on  to  the 
junior  to  get  the  hypo,  ready  for  injecting  antitetanus 
vaccine. 

32.  The   points   of   needles   require   constant   testing. 
Never  boil  up  a  dull  needle.     Test  after  boiling.     Never 


Fig.  11. — Murphy  anastomosis  button,  round,  with  center  collar. 

hand  a  surgeon  a  dull  needle.     Keep  a  large  stock  to 
select  from. 

33.  Scissors   are  tested  on   cotton.     If  they  make  a 
clean  cut,  at  the  tip  first  only,  well  and  good.     Then  try 
the  whole  blade.     Look  for  a  gap  between  the  points. 

34.  Artery  clamps  must  fit  exactly.     If  they  are  too 
loose  or  too  tight  someone  will  have  to  pick  them  from 
the  floor  where  the  angry  surgeon  threw  them. 

35.  Always  put  the  surgeon  in  good  humor  by  laying 
down  a  sharp  scalpel  for  him  to  begin  with. 

36.  Pivot,    mortise,    screw   (applied    to    clamps,   scis- 
sors,   etc.).     See    in    instrument    catalogs.     A    nurse's 
bandage  scissors  have  a  mortise  lock,  slipping  into  place, 


74  OPERATING  ROOM 

a  cleft  over  a  bar,  on  the  bias  or  bevel.  A  pair  of  household 
scissors  have  a  screw  lock.  A  pivot  is  a  straight  bar  pro- 
jection, fitting  at  right  angles  into  a  hole.  All  joints  must 
be  oiled  after  cleaning,  and  the  oil  may  be  boiled  with 
them. 

37.  When  a  second  case  comes  on,  the  scrubbed  nurse — 

(a)  Sorts  her  instruments  and  adds  what  she  had 
previously  selected  for  the  second  case,  clean- 
ing and  boiling  them. 

(6)  Counts  the  used  gloves  into  a  basin. 

(c)  Removes  gown  and  gloves  and  scrubs. 

(d)  Puts  on  new  gown  and  gloves  and  "sets  up" 
with  the  aid  of  another  nurse,  who  opens  drums 
or  packages,  or  she  does  this  herself  before 
scrubbing. 

(e)  Sets   up,   and   asks   for   instruments   to   be 
brought  in,  which  she  cools,  sorts,  etc. 

(/)  Is  all  ready  with  iodin,  sponge  stick,  doctors' 
gowns,  gloves,  lap  sheet,  etc.,  when  the  others 
arrive. 

38.  The  instrument  nurse  must  wash  and  soak  her 
gloved  hands   frequently   during    the   progress   of    the 
case. 

39.  All  tape  sponges  have  a  tape  loop  which  is  slipped 
into  a  heavy  metal  ring  that  hangs  around  an  abdominal 
wound — this  eliminates  the  hateful  sponge  count. 

40.  Sutures  classified  according  to  how  they  are  taken, 
run  in,  and  cut: 

Guy.  Temporarily  put  in  with  a  long  loop  for 
traction  in  place  of  using  vulsella. 

Lembert.  In  and  out  at  one  side  of  the  intestine, 
skipping  the  wound,  and  in  and  out  through 
skin  on  the  other  side. 

Through-and-through.  Stout  silk  or  silkworm-gut 
on  long,  heavy  curved  needle  through  the  skin 
and  deeper  layers  at  once  (but  not  the  peri- 
toneum). 


THE    SCRUBBED    NURSE 


75 


Tier.     Each  layer  by  itself: 
(a)  Peritoneum — fine  catgut  on  small  round 

body  full  curved  needle. 
(6)  Deep  muscle — chromic  gut,  interrupted. 

(c)  Deep  fascia — catgut. 

(d)  Skin — catgut,  silk,  gut,  or  adhesive  only. 
Buried.    Never  to  be  visible  again;  in  deeper 

layers,  and  not  involving  the  skin. 

Running.  One  thread  inserted  several  times 
without  cutting. 

Interrupted.     Knotted  and  cut  at  each  insertion. 

Tension.  A  very  long  suture  beginning  several 
inches  beyond  the  wound  and  passing  through 
the  skin  and  deeper  layers. 

Continuous.    See  Running. 

Pursestring.  A  silk  suture  in  the  intestinal 
tract  to  invaginate  a  raw  area  (the  stump  of 
the  appendix,  for  instance),  on  a  straight  fine 
cambric  needle,  all  the  way  round  in  two  direc- 
tions, and  poking  in  the  raw  gathered  flesh, 
then  tied  securely. 


Fig.  12. — Lane's  bone  plates,  steel,  for  femur,  for  use  in  fractures 

of  bone. 


41.  If  saline  is  used  to  mix  hypos,  in — i.  e.,  cocain, 
novocain,  etc. — it  possesses  certain  advantages: 
(a)  It  is  stimulating. 
(6)  It  increases  the  blood-pressure, 
(c)  It  aids  absorption. 


76 


OPERATING    ROOM 


42.  Hypodermic   needles   made   of   platinum   are   ex- 
cellent.    Though  they  cost  about  $2.50,  it  pays  for  the 
individual  to  have  his  own.     They  last  forever. 

43.  Be  generous  with  finger-cots. 

44.  In  bone-plating,  send  the  junior  to  boil  everything 
each  time  the  surgeon  lays  it  down,  before  taking  it  on 
the  sterile  table  again.     This  requires  an  extra  assistant, 
and  makes  the  operation  long  (Fig.  12). 


mm 


Fig.  13. — The  Albee  electro-operative  bone  set. 

45.  Do  not  boil  electric  apparatus,  especially  the  electro- 
operative  bone  transplantation  instruments  (Fig.  13). 


CHAPTER   V 
THE  HEAD  NURSE 

Preparedness. — This  head  nurse  has  the  work  of  build- 
ing forethought,  honesty,  accuracy,  and  presence  of 
mind  into  a  pupil's  character  more  than  any  other  super- 
visor. But  these  all  come  from  preparedness.  By  co- 
operation with  the  superintendent  of  nurses  a  sane  sys- 
tem of  minor  penalties  should  be  enforced,  since  the 
responsibility  of  conducting  a  case  is  so  great.  If  a  nurse 
is  fatigued  and  does  sloppy  work,  and  it  is  found  on  in- 
vestigation that  she  is  using  too  many  "late  leaves," 
she  should  be  deprived  of  them  for  a  time.  Not  every 
pupil  should  get  the  operating-room  service,  because  it  is 
not  compulsory  and  because  dishonesty  in  doing  simple 
ward  dressings  shows  unfitness.  If  a  nurse  is  honest  and 
accurate  in  the  details  of  ward  work,  she  should  be  sent 
about  the  beginning  of  her  second  year  to  the  operating 
room  when  anatomy  comes  on  the  curriculum,  and  before 
she  begins  to  suffer  from  hospital  fatigue.  By  getting 
this  very  early  she  can  learn  just  as  fast,  and  has  no 
careless  habits  formed,  while  she  is  much  more  useful 
afterward  on  the  wards  in  taking  care  of  an  intravenous 
infusion,  blood-culture  work,  or  phlebotomy  without  any 
agitation. 

The  operating  room  thus  need  not  be  disturbed  for 
any  ward  treatments  of  greater  magnitude.  Besides,  on 
her  second  night  duty  she  can  assume  the  whole  or  a 
large  part  of  the  conduct  of  a  night  emergency  opera- 
tion without  depriving  the  tired  day  nurses  of  their  share 
of  rest.  There  is  a  general  feeling  that  being  in  the 
operating  room  is  a  very  honorable  post,  but  this  is  not 
sufficiently  utilized.  The  superintendent  of  nurses  should 

77 


78  OPEKATING   ROOM 

warn  all  pupils  in  the  early  stages  of  their  career  that  they 
cannot  make  the  operating  room  unless  they  do  good 
work.  If  a  pupil's  first  year  work  is  poor,  better  expel 
her  then  than  at  the  end  of  her  third.  It  is  absolutely 
criminal  toward  patients  and  unfair  to  a  nurse  to  take 
three  years  of  inferior  work  from  her  and  not  give  her  a 
diploma,  while,  again,  giving  her  a  diploma  would  make 
her  the  equal  of  good  nurses  in  the  eyes  of  the  world. 
Considering  then  that  a  nurse  is  worthy  to  receive  the 
training  of  the  operating  room,  the  supervisor  has  yet 
to  show  her  a  million  new  ways  where  she  must  be  accu- 
rate, and  many  new  things  to  resort  to  in  new  emergencies. 
Discipline. — Perhaps  a  little  more  than  the  ward  super- 
visor should  the  operating-room  nurse  be  endowed  with 
power  to  discipline.  She  and  her  nurses  are  in  a  world 
by  themselves.  The  superintendent  might  see  a  pupil 
do  something  wrong,  yet  she  should  not  take  that  pupil 
off  duty  for  fear  of  disturbing  the  service,  nor  "go  in  over 
the  supervisor's  head."  In  a  class  of  20  pupils,  in  a  school 
of  60  nurses,  only  two  of  one  class  probably  are  in  the 
operating  room  at  one  time.  If  they  were  removed, 
possibly  there  might  be  nobody  or  only  one  available  to 
take  their  place,  whereas  in  ward  work,  which  is  more 
flexible,  less  concentrated,  and  among  conscious  patients, 
a  nurse  of  even  the  senior  class  might  not  be  much  missed. 
But  the  superintendent  and  the  supervisor  should  confer 
frequently  at  the  end  of  the  day  and  work  together. 
The  pupils  should  be  kept  at  a  distance,  though  all  live 
on  such  a  close  footing.  There  should  be  no  familiarity 
among  themselves  or  toward  the  supervisor,  who  does 
the  directing,  while  they  listen  silently,  without  chaff  or 
banter.  It  sounds  badly  to  a  patient  waiting  to  be  anes- 
thetized. She  must  say  the  same  things  over  and  over,  and 
has  no  time  to  waste  in  repetition  for  inattention  or  absent- 
mindedness,  though  she  must  be  patient  with  some  who  are 
dull  at  first.  They  should  never  lose  their  whole  "time 
off"  as  a  penalty,  but  they  should  not  get  it  all  if  they 
loaf.  If  they  do  a  thing  badly,  as  cleaning,  they  should 


THE   HEAD    NURSE  79 

lose  the  time  thus  wasted,  and  do  it  again  at  the  sacrifice 
of  a  part  of  their  "time  off."  Forwardness,  quarrelling, 
noisiness  of  voice  or  manner,  improper  dress  or  toilet  of 
the  hair  and  person  (perspiration,  highly  scented  powders, 
and  waters)  should  be  checked  at  once  by  loss  of  the  cap, 
degradation  of  position  (put  back  from  "instruments"  to 
"dirty  nurse,"  for  instance),  and  other  penalties  in  pro- 
portion to  the  offence.  Ward  nurses  sending  up  a  pa- 
tient improperly  shaved  or  badly  prepared  so  that  he 
stools  on  the  table  should  be  reported  to  and  severely 
punished  by  the  superintendent  of  nurses. 

Teaching. — The  head  nurse  must  demonstrate  all  the 
work  of  the  floor  to  her  staff.  This  is  severely  eliminated 
by  the  demonstrator  who  teaches  nursing  all  through  the 
rest  of  the  hospital  because  of  the  variations  in  technic. 
Let  us  hope  it  will  soon  be  standardized!  As  the  pupils 
ascend  the  scale — dirty  nurse,  anesthetic  nurse,  and  in- 
strument nurse — they  must  be  shown.  Then  they  should 
do  the  thing,  for  her  to  criticise,  without  any  case.  Then 
they  should  do  the  thing  during  the  operations,  with  her 
standing  back  of  them  and  helping  them.  If  a  perfect 
rotation  of  pupils  is  executed,  they  pass  out  to  do  night 
duty,  and  obviate  thus  the  necessity  of  calling  her.  She 
should  get  perfect  rest.  She  should  maintain  all  her  vigor, 
since  she  is  a  very  valuable  member  of  the  staff.  Night 
work,  relief  work,  and  vacation  substitution  always  form 
an  excellent  school  to  give  the  pupils  self-reliance.  Like 
an  infant,  they  must  be  made  to  stand  alone.  Even  the 
least  promising  do  well  when  left  to  themselves,  being 
quite  proud  and  feeling  untrammelled. 

When  a  nurse  shows  lack  of  theoretic  knowledge,  this 
should  be  reported  to  the  teacher  of  those  special  subjects 
in  which  she  failed,  as  anatomy  or  materia  medica,  and 
the  points  specified.  Before  each  day's  operations  begin 
by  a  series  of  plates,  charts,  instrument  catalogs,  cards  of 
samples,  etc.,  she  should  teach  the  nurses  their  several 
duties  for  those  cases  on  a  very  scientific  basis,  quizzing 
them  on  the  anatomy  of  the  parts  and  the  nursing  details. 


80  OPERATING   ROOM 

She  must  demonstrate  all  the  work  of  (1)  scrubbing  up; 
(2)  the  positions;  (3)  setting  up;  (4)  binders;  (5)  opening 
all  sterile  goods;  (6)  making  saline,  etc.;  (7)  running  all 
the  sterilizers. 

She  must  pay  special  attention  to  nice  points  in  asepsis 
and  technic,  so  that  each  pupil  will  feel  it  her  stern  duty 
to  do  these  things  with  the  same  meticulous  care:  (1)  fold- 
ing linen;  (2)  opening  a  sterile  towel;  (3)  setting  up; 
(4)  handing  a  needle-holder;  (5)  pouring  out  medications; 
(6)  conducting  a  case. 

She  must  instruct  the  senior  in  the  special  whims  or 
methods  of  certain  surgeons,  with  their  reasons,  so  that 
they  will  not  forget. 

Details  in  Nursing. — Apart  from  the  question  of  technic 
there  is  a  great  deal  of  general  nursing  care.  A  patient 
must  not  be  poisoned  with  a  too  strong  bichlorid  of 
mercury  solution,  nor  burned  with  iodin  confined  (i.  e., 
running  down  the  buttocks  to  the  spine),  nor  bruised  by 
somebody  leaning  on  her,  nor  paralyzed  by  standing  up- 
side down  in  Trendelenburg  on  shoulder-rests  badly 
padded.  The  nurses  should  all  follow  up  the  cases  in  the 
wards  and  know  how  they  are  doing,  whether  they  have 
primary  union,  whether  packing  is  removed  as  specified, 
etc.  The  head  nurse  should  confer  frequently  with  the 
ward  head  nurses.  The  operating  pupil  bringing  down  a 
case  should  be  "released"  on  the  word  of  the  nurse  "receiv- 
ing" him  that  his  dressings,  gown,  and  binder  are  O.  K. 
The  position  of  all  hypodermic  injections  given  in  the 
operating  room  should  be  charted:  "Strych.  sulph.,  gr.  ^r, 
by  hypo.,  in  the  left  upper  arm,  half-way  up,  on  the  outer 
side,  given  by  Margery  Daw."  Blame  is  tossed  forward 
and  back  from  one  service  to  another,  until  some  one  thus 
stamps  the  blame  on  the  real  wrong  doer.  The  nurses 
must  retain  their  "nursing"  sense,  and  this  is  helped  by 
sending  them  to  the  wards  on  Sundays  and  holidays  to 
relieve.  The  patient's  modesty  must  be  considered 
whether  under  an  anesthetic  or  not.  She  must  be  draped, 
and  no  exposure  made  where  unnecessary  at  any  time. 


THE    HEAD    NURSE  81 

Colored  physicians  are  not  allowed  to  witness  operations 
on  any  women  but  of  their  own  race,  as  a  rule,  even  in  the 
charity  wards.  All  tampons,  packing,  etc.,  must  be 
reported  to  the  wards.  Conversation  should  be  just  as 
guarded  as  if  the  patient  were  listening.  It  is  sometimes 
feared  that  standards  are  lowering.  Formerly  a  nurse 
was  completely  disgraced  if  her  patient  was  badly  pre- 
pared. Now  it  is  not  properly  reported  to  the  super- 
intendent, and  the  nurse  is  not  punished  enough,  if  at  all — 
the  result  is,  increasing  indifference.  The  orderly  should 
not  be  present  when  women  are  operated  on  for  any  con- 
dition. 

Common  Faults  in  Operating  Rooms. — There  should 
never  be  a  complaint  from  the  surgeon  about  the  common 
subjects — (1)  dulness  of  instruments  and  needles;  (2) 
bad  condition  of  the  cautery  or  aspirating  set.  One 
should  strive  to  be  above  all  others  in  such  things.  One 
should  learn  from  others'  mistakes.  One  should  avoid  all 
the  monotonous  banalities  of  this  life. 

Legal  Phases. — There  are  many  features  in  which  a 
trusty  supervisor  stands  as  the  confidential  agent  of  a 
busy  or  absent-minded  surgeon  who  has  grown  to  lean 
on  her  memory  and  judgment.  In  a  new  position  a  young 
nurse  should  not  venture  to  assume  some  of  these  burdens, 
but  after  she  has  "made  good"  it  may  be  relegated  to  her. 
At  any  rate,  this  is  the  time  to  teach  the  pupils  that  a 
minor  cannot  be  operated  on  without  the  consent  of  his 
parents;  that  a  woman's  generative  and  other  organs  may 
not  be  removed  without  her  own  and  her  husband's  con- 
sent when  found  diseased  upon  exploration;  that  all  cases 
must  be  completely  recorded,  for  reference  in  possible 
future  lawsuits;  that  the  patient's  interests  must  be  pro- 
tected as  well  after  he  is  anesthetized  as  before.  A  case 
is  cited  of  a  young  girl  undergoing  the  operation  of  ton- 
sillectomy.  Another  physician  accompanied  her,  and 
after  she  was  anesthetized  he  asked  permission  of  the 
surgeon  to  make  a  gynecologic  examination,  upon  doing 
which  he  made  certain  remarks  which  showed  clearly  that 


82  OPERATING   ROOM 

he  had  not  been  acting  for  some  time  as  her  physician, 
but  merely  wished  to  know  what  had  transpired  in  the 
interval  since  he  had  had  charge  of  her  case.  This  need 
not  have  taken  place  at  all  in  those  surroundings.  Once 
in  a  while  when  ethical  courtesy  is  extended  it  is  abused. 

Routine. — There  are  many  duties  to  be  performed. 
In  some  hospitals  all  the  surgical  supplies  are  assigned  to 
this  supervisor,  who  distributes  them  on  Saturdays  (the 
best  day  to  avoid  the  old-fashioned  Sunday  dearth  of  every- 
thing) on  the  ward  requisitions.  Rounds  must  be  made 
over  the  whole  floor  daily  for  general  cleanliness,  weekly 
for  special  cleaning,  and  at  other  longer  intervals  for  keep- 
ing up  the  good  appearance  given  by  painting  and  plaster- 
ing. In  the  evening  before  going  off  duty  it  should  be 
the  regular  duty  of  the  supervisor  to  know  that  her  staff 
is  leaving  its  saline,  infusion  sets,  etc.,  in  perfect  readiness 
for  a  night  call,  and  that  everything  is  done  that  can  be 
done  on  that  day.  Let  no  work  be  carried  over  to  another 
day.  A  book  of  house  rules  must  be  kept  drawn  up 
and  at  regular  intervals  revised  by  the  Medical  Board. 
There  must  be  a  general  stock-taking  on  certain  dates  of— 

(1)  The  ward  dressings  and  linen  (of  a  certain  uniform 
design) : 

(a)  In  actual  use. 
(6)  Sterilized  reserve. 

(c)  Unsterilized    reserve,    done    up    in    covers, 

ready. 

(d)  Fluffs,  wipes,  etc.,  made,  but  not  put  up. 

(e)  Empty  covers  (sorted),  including  what  is  in 

the  laundry. 

(2)  The  operating-room  dressings  (of  different  design) 
and  linen: 

(a)  In  actual  use. 

(6)  Sterilized  reserve. 

(c)  Unsterilized  reserve,  put  up,  ready. 

(d)  Fluffs,  tapes,  etc.,  sewed,  but  net  put  up. 

(e)  Empty  covers  (sorted),  including  what  is  in 

the  laundry. 


THE    HEAD    NURSE  83 

(3)  The  operating-room  special  goods — saline,  tubing, 
pledgets,  etc. 

There  should  be  a  list  made  up  of  each  class,  with 
a  number,  agreed  on  by  the  superintendent,  the  super- 
intendent of  nurses,  and  the  operating-room  super- 
visor. She  then  feels  free  to  order  muslin  to  make 
enough  covers  or  towels,  etc.,  to  keep  up  her  stock.  It 
allays  anxiety  to  have  a  big  reserve,  and  it  does  not  cost 
any  more  once  it  is  started.  There  should  be  a  regular 
time  for  making  saline  solution,  so  that  each  pupil  makes 
it  so  often,  and  it  must  be  watched  for  cloudiness.  But 
if  there  is  a  rush,  it  should  be  made  at  once,  and  if  once 
sterilized,  is  good  for  the  night  at  least.  The  nurses, 
maids,  and  orderly  must  be  constantly  supervised  at  all 
their  work.  By  a  daily  slip  the  head  nurse  reports  at 
the  office  all  needed  repairs  and  emergency  supplies  and 
her  own  "time  off,"  since  she  is  a  very  important  official. 
The  engineer  cannot  get  good  service  out  of  his  men  if 
he  does  not  get  his  requisitions  early  so  as  to  assign  them 
their  work  before  9  o'clock.  A  careful  buyer  has  few 
emergency  supplies  to  ask  for.  The  nurses'  work  is  com- 
pletely mapped  out  for  the  day  according  to  the.  schedule 
of  operations  listed  in  the  office  the  evening  previous. 
The  supervisor  should  work  the  anesthetic  nurse  into 
minor  operations,  etc.,  when  the  "scrubbed  nurse"  is 
"off  for  her  time"  before  her  term  is  out  in  the  anesthetic 
room,  and  so  on  with  all  of  them.  The  pupils  should 
not  all  go  newly  into  the  three  positions  on  the  same 
date.  If  the  wards  are  extravagant  with  gauze  the 
pupils  there  should  come  up  and  help  make  dressings  at 
night  for  an  hour,  to  see  how  it  feels  up  there  from  that 
standpoint.  The  head  nurse  assists  in  buying  goods  for 
her  department  and  instructs  her  senior  pupil  at  the 
same  time.  She  knows  what  sick  cases  use  up  the  gauze 
and  cotton.  She  knows  how  much  work  is  required  in 
cutting,  folding,  and  sterilizing,  and,  having  it  in  charge, 
she  is  not  prone  to  hand  it  out  too  indulgently.  But  she 
also  knows  equally  well  which  maker's  instruments  last 


84  OPERATING   ROOM 

well,  who  does  the  best  and  quickest  repairs,  what  kind 
of  goods  is  satisfactory  to  the  operators,  and  how  the 
patient  fares  under  a  cheap  ether  or  a  new-fangled  anes- 
thetic. The  patient  first,  last,  and  always!  Any  mechanic 
should  have  the  choice  of  his  tools,  but  when  the  super- 
intendent says,  "Why  won't  this  gauze  do?"  there  must 
be  a  scientific  answer.  It  is  sleazy,  not  enough  threads 
to  the  inch,  or  cotton  may  be  lumpy,  friable,  and  dirty, 
rubber  malodorous,  or  instruments  ill-fitting  and  badly 
plated.  The  supervisor  must  encourage  the  pupils  to 
tell  every  word  of  approval  or  complaint  from  the  sur- 
geons, investigating  the  latter,  since  she  is  really  the 
medium  between  them  and  the  office.  They  forget  as 
they  walk  downstairs  all  the  things  they  thought  of  under 
the  stress  of  operating.  It  takes  a  "live  wire"  to  do  all 
these  things  to  improve  the  surgical  service  and  make  it 
run  smoothly.  One  nurse  is  appointed  to  care  for  all  the 
instruments  in  the  house;  to  see  that  ward  sets  are  in- 
tact; to  trace  a  missing  one;  to  make  the  one  who  used  it 
last  pay  for  it;  to  list  all  needing  repair;  to  check  them 
off  when  they  come  back;  to  have  some  renickeled  regu- 
larly; to  exchange,  with  the  supervisor's  approval,  poor 
ward  instruments  for  fair  duplicates,  and  get  new  for  the 
operating  room,  subject  to  the  instrument  committee; 
to  lend  no  apparatus  without  the  consent  of  the  surgeon 
on  service;  to  get  it  back  promptly,  by  frequent  tele- 
phoning, from  the  forgetful  borrower,  and  to  give  out  no 
sterile  dressings  to  any  purchaser  without  an  order  from 
the  office  showing  that  he  has  paid  for  it  or  had  it  charged. 
At  the  end  of  each  case  the  supervisor  should  "viser" 
each  slip  pinned  on  the  chart  for  the  ward  nurse's  imme- 
diate use,  checking  it  up  as  to  drainage,  name  of  opera- 
tion, etc.,  and  she  personally  inspects  each  patient's 
condition  as  to  pulse,  wrappings,  binder,  etc.,  before  he 
goes  down  to  bed.  She  designates  which  tables  will  be 
used  for  certain  cases.  She  maintains  perfect  decorum 
among  all  her  staff,  so  that  her  commands — in  a  low, 
clear  tone — may  be  easily  grasped.  Signs,  frowns, 


THE   HEAD    NURSE  85 

whispers  are  very  ineffectual  and  confusing  to  a  novice. 
Messages  taken  by  a  pupil  outside  are  written,  and  if 
the  supervisor  judges  them  urgent  are  held  in  front  of 
the  surgeon's  eyes.  The  assisting  intern  must  receive 
messages  while  a  case  is  on.  Seven  or  eight  other  doctors 
and  a  hundred  or  more  other  patients  have  some  claims 
on  him.  The  head  nurse  also  will  keep  an  accurate  ac- 
count of  all  narcotics,  under  the  Harrison  law,  as  to 
amount  received  and  how  disposed  of,  of  stimulants, 
such  as  brandy  (hypos.)  and  whisky  (enemata),  of  de- 
natured alcohol  (not  designed  for  nurses'  alcohol  lamps 
nor  orderlies'  tippling),  and  of  radium. 

Sterile  goods  must  be  accessible  for  the  benefit  of  the 
night -staff  through  the  night  supervisor  only,  who  renders 
a  strict  statement  of  instruments,  saline,  or  dressings 
taken.  The  staff  must  take  part  in  all  fire-drills.  She 
makes  rounds  on  the  wards  irregularly  to  see  whether 
sterile  goods  are  wasted  or  not.  She  should  encourage 
each  ward  nurse  to  build  up  in  a  small  locked  closet  a 
reserve  of  dressings  for  night  or  other  emergencies,  and 
should  help  to  foster  a  cordial  feeling  between  day  and 
night  staffs.  It  must  be  repeated  that  a  large  sterile 
reserve  is  imperative  in  view  of— 

(1)  Any  epidemic  among  the  pupils. 

(2)  A  breakdown  of  the  sterilizers  or  steam-fittings. 

(3)  A  general  calamity  in  the  town — i.  e.,  fire,  accident, 
etc. 

She  must  direct  the  reading  of  her  pupils  on  materials 
relating  to  their  present  work,  especially  of  such  authors 
as  Dr.  Brickner  and  Dr.  Fowler.  She  must  confer  fre- 
quently with  the  housekeeper  and  the  matron  of  the 
linen-room  in  regard  to  stains,  bleaches,  wear  and  tear, 
slow  service,  lost  articles,  patterns,  materials,  and  suits. 
She  sees  that  the  nurses  wash  out  all  blood,  feces,  and 
clots  before  sending  linen  to  the  laundry,  and  that  all 
iodin  stains  are  removed  first  also.  Use  a  doll's  wash- 
board for  small  articles  in  a  sink  with  a  stopper,  and  a 


86  OPERATING   ROOM 

real  laundry  tub  for  large  sheets  to  save  time  in  the 
model  "hopper"  room.  This  is  not  the  orderly's  work. 

It  constitutes  a  part  of  a  nurse's  training  to  clean  up 
everything  after  her  case,  especially  unsightly  blood. 
She  must  keep  a  well-bound  register  that  will  last  for- 
ever, with  the  address  of  the  maker  and  the  number  of 
the  design  pasted  inside  for  reference  in  ordering  again, 
and  in  case  of  fire  this  book  should  be  saved.  It  con- 
tains a  complete  account  of  the  case — patient's  name, 
chart  number,  age,  date,  operator,  all  assistants,  charge 
nurse,  other  nurses,  operation,  drainage,  stimulation, 
dressings,  anesthetics  of  various  kinds,  duration  of  each, 
anesthetist,  patient's  condition.  She  keeps  also  a  book 
with  a  standard  number  of  dressings,  towels,  and  band- 
ages allowed  each  ward  that  it  must  not  exceed,  and  in 
giving  out  dressings  daily  usually  exchanges  empty  for 
full  covers,  with  the  understanding  that  the  balance  is 
full  on  the  ward.  A  special  requisition  for  more  must 
be  obtained  from  the  superintendent  of  nurses,  who,  if 
doing  her  duty,  knows  the  exact  needs  of  each  patient. 
Pupils  should  not  run  promiscuously  to  the  operating 
room  for  goods.  But  if,  outside  the  fixed  hour,  an  anxious 
little  head  nurse  presents  herself  apologetically  she  should 
not  be  met  with  a  stony  glare.  Give  her  the  goods  and 
investigate  afterward.  Bad  management  is  not  a  crime 
and  accidents  or  mistakes  occur.  Each  ward  nurse  should 
order  ahead,  and  should  know  a  day  ahead  when  new 
drains  of  rubber  or  the  "cigarette"  will  be  needed,  not 
waiting  until  the  surgeon  comes.  It  is  much  better  dis- 
cipline to  catch  that  pupil  and  make  her  do  an  hour's 
work  on  drains  after  she  has  finished  on  her  ward. 

She  should  look  after  the  health  of  her  staff,  the  clean- 
liness of  their  hair,  the  style  of  shoes,  their  throats, 
and  their  skin.  Bichlorid  rashes  must  be  avoided.  If 
they  occur,  nightly  dressings  of  lanolin  are  best.  Dutch 
Cleanser  and  other  powerful  agents  for  chasing  dirt 
must  be  used  only  while  wearing  coarse  rubber  gloves 
by  some  thin-skinned  folk.  Nurses  must  wash  off  the 


THE    HEAD    NURSE  87 

soap  thoroughly  before  immersing  in  bichlorid,  as  the 
neglect  of  this  causes  a  black  scale  and  cracks.  It 
is  not  necessary  to  scrub  with  a  brush  above  the  wrists. 
A  nurse's  skin  is  too  fine.  To  dry  the  hands  thoroughly 
each  time  they  are  wet  and  use  a  dash  of  hand  lotion 
is  effectual  in  saving  the  skin,  and  all  this  is  for  the 
general  benefit.  Keeping  each  nurse  fit  is  advantageous 
to  all.  The  supervisor  requires  alertness,  suavity,  self- 
control,  a  fine  but  not  dominating  sensitiveness,  op- 
timism, power  to  build  a  well-formed  schedule  for  each 
day,  and  a  well-defined  plan  for  the  future.  These  are 
some  of  the  salient  features  we  so  gladly  find  in  some  and 
so  sadly  miss  in  others.  Upon  review  of  all  the  operating- 
room  supervisors  one  has  known,  how  many  measure  up 
to  these  standards?  We  cherished  resentment  for  the 
time  that  one  posed  to  the  gallery  of  students  (only  in 
their  third  year  at  that),  that  another  spent  most  of  her 
time  talking  to  the  interns,  or  that  a  third  had  no  head 
for  management!  But  a  supervisor  in  such  a  strenuous 
life  needs  a  greater  amount  of  vacation  and  change  of 
scene,  for  why  should  she  grow  gray-haired  faster  than 
the  others  on  the  wards?  Then  it  is  the  duty  of  the 
Directors  to  pay  her  such  a  salary  that  she  can  keep  her- 
self fit  and  retain  the  position  long  enough  to  work  to 
their  advantage. 

Ethical  Relation  to  the  House. — The  operating  room 
is  the  common  stamping-ground  for  men  who  have  some 
reasons,  real  or  fancied,  for  jealousy.  The  supervisor 
can  do  a  great  deal  to  quell  or  feed  this  by  tact  or  gossip, 
by  hustling  a  little,  or  complaining.  She  must  be  fair 
and  just  to  all.  No  one  man  should  be  allowed  to  begin 
a  case  so  late  that  he  knows  it  will  overrun  his  time 
allotted.  But  she  cannot  hinder  him.  The  hospital  com- 
mitte.es  decide  that.  She  should  report  any  whimsical 
technic,  so  that  it  may  be  regulated  by  the  committee, 
who  will  back  her  strongly  if  she  is  honest.  To  be  honest 
does  not  mean  to  hide  things  and  to  connive  without  words 
at  favoring  one. 


88  OPERATING   ROOM 

The  hospital  must  be  humane,  but  it  cannot  under- 
take to  use  the  time  of  its  pupils  to  make  dressings  for 
sale  or  gift  to  any  and  every  physician  whose  own  family 
could  easily  learn.  But  if  a  doctor  receives  a  hurry  call 
while  in  the  hospital,  on  the  close  of  his  morning  rounds, 
when  his  supplies  are  gone,  he  can  buy  a  few  at  what 
it  costs  to  produce  them.  He  should  send  back  the 
covers  promptly.  If  a  physician  presents  a  certain 
article  to  the  hospital  it  should  have  no  string  to  it.  He 
should  not  keep  borrowing  it  back,  because  had  it  not 
been  given  the  hospital  would  have  had  one  of  its  own. 
The  making  of  saline  is  a  delicate  matter,  seldom  well 
done  outside  a  hospital,  but  it  does  not  undertake  to 
make  saline  for  sale  or  gift.  People  who  need  saline, 
dressings,  etc.,  should  come  to  the  hospital  as  patients. 
However,  some  towns  are  very  poorly  equipped  for 
contagion,  and  some  hospitals  charge  tremendous  prices, 
and  all  these  questions  need  deliberation.  The  super- 
visor, therefore,  must  have  no  relations  with  the  outside 
world  professionally,  except  through  a  council  of  two 
people — (a)  the  superintendent  of  nurses,  who  should 
not  lend  herself  to  lowering  the  standards  for  caring  for 
and  teaching  nurses;  (6)  the  superintendent,  who  is  sup- 
posed to  know  the  policy  of  the  Governors  toward  the 
municipality. 

Advancement. — It  is  hoped  that  the  wonderful  work 
of  the  American  Hospital  Association  will  bear  as  much 
fruit  in  efforts  to  standardize  operating-room  technic 
as  it  has  done  in  other  spheres.  The  small  hospitals 
were  the  first  to  call  for  this  because  they  suffer  more. 
The  number  of  whims  and  the  kinds  of  goods  should 
be  reduced  to  a  minimum.  The  greater  the  surgeon,  the 
fewer  fads  and  instruments.  Then,  if  the  association 
helps  operating-room  nurses  this  way,  it  should  standardize 
their  attainments  by  demanding  some  proof  of  their  fit- 
ness. If  an  examination,  theoretic  and  practical,  in 
operating-room  technic  were  held  every  three  years,  and 
each  operating  nurse  successfully  passed  and  had  her 


THE    HEAD    NURSE  89 

certificate  restamped,  it  would  prove  to  a  superintend- 
ent from  whom  she  sought  employment  that  she  should 
make  good,  instead  of  being  passed  along,  like  a  maid  or 
a  dressmaker,  as  at  present,  by  only  verbal  commenda- 
tion. Each  operating-room  nurse  should  visit  other 
hospitals  regularly,  and  should  arrange  similar  visits  for 
her  pupils,  for  comparison,  instruction,  and  maybe,  also, 
self-congratulation  at  times.  She  should  at  all  times 
successfully  demonstrate  economy  for  the  benefit  of  not 
only  the  hospital,  but  her  pupils'  future  careers.  Ends 
of  bandages  may  be  used  for  packing.  Edges  of  gauze- 
folds  will  make  stuffing  for  pads.  Catgut  need  not  be 
thrown  away  if  the  pupil  is  taught  the  anatomy  of  the 
part  to  be  sutured.  Stains  washed  out  will  prevent  de- 
struction by  strong  bleaches.  All  the  control  of  surgical 
goods  in  one  hand  centralizes  and  regulates  their  con- 
sumption. In  a  thousand  ways,  not  by  getting  cheap 
materials,  but  by  using  every  bit  of  good  goods,  are  true 
economy  exhibited  and  good  results  obtained. 


CHAPTER  VI 

THE  MAIN   OPERATING  ROOM 

THIS  subject  has  been  admirably  handled  by  many 
writers,  but  without  quoting  their  opinions  conclusions 
similar  to  theirs  may  frequently  be  worked  out  under 
somewhat  similar  conditions.  It  would  be  impossible  to 
graft  a  really  ideal  operating  room  on  an  old  plant.  A 
hospital  is  a  growth.  But  even  one  of  the  points  here 
mentioned  may  prove  of  value  in  remodelling  old  build- 
ings, and  while  all  might  not  be  possible  in  a  new  plant, 
yet  they  are  suggested  as  a  means  of  facilitating  the  labor 
of  the  surgeons  and  nurses,  having  been  the  result  of 
years  of  actual  work  in  various  operating  rooms  (Fig.  14) . 

Position. — The  operating  suite  should  be  cut  off  from 
the  busy  parts  of  the  institution  and  yet  be  within  easy 
reach.  No  odor  of  ether  should  offend  the  rank  and  file 
of  visitors.  No  noise  of  visiting,  laundry  or  garbage 
cans  should  disturb  the  surgeons.  This  should  be  a 
"holy  of  holies,"  to  help  clear  thought,  precise  calcula- 
tion, and  quick,  clean  action.  The  light  should  not  be 
from  the  direct  rays  of  the  sun,  but  preferably  from  the 
north,  in  these  latitudes  being  more  equally  diffused  and 
casting  no  strong  shadows.  A  skylight  is  cold  and 
uncleanly,  but  a  glass  wall  projecting  out  2  feet  to  the 
north,  with  east  and  west  windows  and  storm  sashes,  is 
very  excellent. 

Ventilation  by  the  direct  method  should  be  of  a  very 
simple,  easy,  yet  germ-proof  style,  so  that  it  may  safely 
be  operated  by  anyone,  but  not,  however,  thrown  di- 
rectly on  the  patient.  In  this  projection,  which  is  ren- 
dered opaque  to  cause  privacy  and  prevent  nurses  from 
absent-mindedly  staring  out,  should  be  set  separate 
panes  with  a  swinging  leaded  glass,  preferably  up  and 

90 


THE    MAIN    OPERATING    ROOM 


91 


Fig.  14. — Model  operating-room  suite. 


down,  in  a  curved  box  following  the  path  of  the  pane,  the 
floor  of  this  box  being  fitted  with  the  finest  wire  netting. 
Frosted  glass  causes  an  equal  diffusion  of  light. 


92  OPERATING   ROOM 

Temperature. — The  engineering  department  should 
be  equipped  to  send  forced  drafts  in  summer  of  cool 
washed  air,  but  unsteamed,  from  the  sterilizing  room,  and 
in  winter  of  warm  washed  but  unsteamed  air  into  the 
central  room  where  the  wounds  are  made.  Hot- water 
heating  (75°  to  80°  F.)  is  also  quite  favorably  considered, 
in  which  case  the  radiators  should  be  composed  of  coils 
so  spaced  as  to  permit  easy  daily  cleaning,  since  cold  air 
carries  to  them  the  dust  which  their  heat  redistributes. 
If  on  the  floor  radiators  should  be  covered  with  white 
boxed  muslin  covers,  laundered  daily,  to  prevent  that 
fan-shaped  distribution  of  dust  that  clouds  the  walls, 
to  say  nothing  of  the  vital  statistics.  There  are  modern 
hot-water  coils  built  up  the  wall  which  largely  obviate 
the  dust  trouble,  since  the  coldest  water  is  at  the  bottom. 
For  the  patient's  sake  the  heat  should  be  quite  uniform 
when  he  passes  from  one  room  to  another,  especially 
going  back  to  bed,  since  ether  opens  every  pore.  This 
uniformity  of  temperature  is  more  likely  to  be  wholesome 
for  the  nurses  also,  who  perspire  freely  during  operations. 
During  the  progress  of  a  case  the  patient  is  quite  scantily 
clad.  Limbs  suspended  in  mid  air  a  long  time  grow  very 
cold  even  in  a  warm  room.  Trendelenburg  always  gives 
cold  feet.  The  staff,  therefore,  should  dress  lightly  to 
endure  the  temperature  which  the  patient  needs.  Com- 
mon sense  is  necessary  in  judging  what  is  suitable  for 
nurses,  the  supervisor  setting  them  an  example  in  modesty 
and  becomingness  regarding  caps,  collars,  neck-bands, 
sleeves,  shoes,  etc.  There  should  be  no  decollete  effects. 
Outside  the  actual  operating  room  the  full  uniform 
should  be  worn,  i.  e.,  the  moment  a  case  is  finished  the 
nurses  should  take  off  cap  and  gown  to  clean  up.  Special 
gowns  of  light  muslin  or  Indian  head  and  caps  of  sheer 
lawn  are  devised  for  this  purpose,  and  should  be  plentifully 
provided  in  all  sizes  and  lengths. 

It  is  positive  cruelty  as  well  as  waste  of  effort  to  make 
human  beings  work  in  steam-laden  air.  Steam  causes 
undue  perspiration  and  loss  of  energy,  spoils  the  instru- 


THE    MAIN    OPERATING    ROOM  93 

ments  standing  in  closed  cases,  and  chips  off  paint.  The 
sterilizing  room  should  be  cut  off  at  its  entrance  from  the 
rest  of  the  suite  by  an  open-air  corridor  or  shaft  from  some 
roof-garden  or  balcony  above  and  below.  The  pipes 
from  the  sterilizing  room,  running  into  the  operating 
room  from  the  sides,  are  not  affected  by  this.  It  will 
take  the  fertile  ingenuity  of  a  modern  architect  to  solve 
the  problem  of  this  open-air  shaft,  but  it  must  be  done. 
A  skylight  in  the  sterilizing  room  partly  obviates  the 
difficulty.  The  steam  vents  should  be  connected  with 
the  open  air,  but  visible  through  glass.  Until  these  two 
features — of  an  open-air  shaft  outside  the  entrance  to  the 
sterilizing  room  and  hoods  connected  with  the  outer 
atmosphere  over  the  steam  vents — are  worked  out  there 
will  be  a  constant  drain  of  energy  for  nothing.  The 
steaming  or  boiling-up  of  instrument  and  utensil  steril- 
izers, and  the  opening  of  certain  windows  to  confine  this 
steam  where  it  belongs  or  to  chase  it  outdoors,  must  in 
any  case  be  carefully  attended  to  by  a  thoughtful  super- 
visor. It  is  not  sane  to  confront  a  highly  skilled  profes- 
sional man  like  a  surgeon  with  the  same  disagreeable 
conditions  that  form  the  subject  of  eager  charitable  public 
investigation  in  factories,  when  he  saves  lives  and  the 
factories  simply  make  paper  or  cloth.  When  a  life  is  at 
stake,  for  one  crucial  space  of  time,  everything  preserving 
vigor  and  presence  of  mind  is  an  asset  for  the  whole 
municipality. 

Corners. — Coved  corners  are  best  for  ceiling  and 
floor.  To  free  the  room  from  germs  the  best  method  is 
to  turn  on  live  steam  for  an  hour  by  special  pipes  and 
other  fixtures  from  the  boiler-room,  adjusted  outside  the 
operating-room  door. 

Fumigation  is  declared  out  of  date,  but  if  still  resorted 
to  requires  special  attention  to  these  points: 

(1)  Leave  one  window  unsealed,  but  closed. 

(2)  Put  a  damp  towel  over  the  face  when  entering  to 
open  up. 


94  OPERATING   ROOM 

(3)  Formaldehyd  is  a  germicide  (KMnO4  Biv  to  forma- 
lin Oj  to  every  1000  cubic  feet  of  air  space). 

(4)  Sulphur  is  an  insecticide  only. 

(5)  Seal  up  all  apertures  connecting  with  hot-air  shafts, 
etc. 

(6)  Protect  the  floor  from  stains  by  the  overflow  in  the 
chemical  reaction  of  the  permanganate. 

(7)  Leave  nothing  inside  that  can  be  boiled  or  steam- 
sterilized,  in  case  it  may  be  needed. 

(8)  Have  some  place  else  to  work  in  if  this  room  is 
closed. 

Any  day  a  case  may  be  operated  on  that  shows  ty- 
phoid bacilli,  tuberculosis,  or  some  of  the  exanthemata, 
and  it  is  an  important  asset  to  be  able  to  disinfect  the 
whole  room  quickly  and  easily.  In  its  broadest  sense, 
the  "operating  room  is  never  out  of  commission."  Some 
special  instrument  might  be  needed  the  moment  the 
live  steam  was  turned  on,  and  the  impossibility  of  getting 
it  might  seriously  delay  another  case.  The  operating 
room  is  in  no  sense  a  store-room,  and  it  is  not  the  cleanest 
room  in  the  house,  since  purulent  cases  are  opened  up 
there,  and  people  come  off  the  street  to  view  opera- 
tions. There  should  always  be  a  simple  plain  store- 
or  stock-room  nearby,  well  cared  for,  to  work  in  for  a 
day. 

The  instrument  cases  should  be  kept  outside  the 
operating  room,  with  labels,  tags,  names,  and  numbers 
according  to  the  kind  of  goods,  the  surgeon  who  owns 
them,  their  sizes,  and  other  individual  traits,  so  that  they 
may  be  found  in  haste.  An  instrument  should  have  a 
uniform  name  according  to  its  purpose.  On  each  shelf 
should  lie  a  list  of  all  the  instruments  on  it. 

We  must  distinguish  between  the  sterilizers  that  are 
run  for  the  whole  house  and  those  run  for  the  immediate 
benefit  of  the  patient  on  the  table.  For  an  operation 
everything  needed  in  it  should  be  as  close  as  possible, 
and  other  things  quite  far  away. 


THE    MAIN    OPERATING    ROOM  95 

It  is  not  advisable  always  for  the  supervisor  to  scrub. 
Careful  drill  on  her  part,  talks  in  anatomy,  lessons  on 
sutures,  a  quiz  before  each  case,  and  a  graduated  sequence 
of  duties  will  fit  her  nurses  to  pass  instruments.  The 
most  skilful  nurse  should  be  least  hampered.  Some 
women  who  are  paid  to  supervise  love  to  get  into  a  sterile 
gown,  intrenched  behind  which  they  give  frowning  orders 
that  confound  and  perplex  the  pupil,  making  her  resent- 
ful and  conscious.  If  the  surgeons  do  their  share  cheer- 
fully in  training  the  pupils,  and  show  self-control,  not 
anxiety,  when  a  new  pupil  reaches  the  instrument  table, 
they  will  be  rewarded  by  enthusiastic  devotion.  All 
the  arrangements  of  the  operating  room  form  the  keys 
and  stops  of  a  big  organ,  and  the  best  skilled  player  is 
the  supervisor,  but  she  cannot  play  a  fugue  by  choosing 
only  to  work  the  bellows.  She  should  be  free  to  super- 
vise a  second  case  in  another  room,  or  in  many  rooms, 
according  to  the  size  of  the  institution. 

Many  small  hospitals  feel  that  they  cannot  afford  a 
second  small  operating  room  for  pus  cases.  This  mooted 
question  brings  up  the  difficulty  of  diagnosing  the  pres- 
ence of  pus.  In  any  case,  a  "septic"  operating  room 
should  be  steam-sterilized  every  time  it  is  used,  and  left 
aseptic. 

Dark  Room. — Again,  for  all  the  "scopic"  work,  whether 
it  be  cystoscopic,  laryngoscopic,  or,  again,  submucous 
operating,  the  dark-room  is  necessary.  Any  room 
should  be  easily  converted  into  a  dark  room,  but  it  should 
not  be  one  that  might  be  needed  simultaneously  for 
another  purpose.  If  the  Medical  Board  would  assume 
its  responsibility  this  could  be  decided  by  the  amount  of 
work  done  by  the  man  desiring  the  "dark  room."  If 
his  cases  are  very  few,  they  could  be  done  at  night  in  the 
main  room.  It  makes  for  uncleanliness  to-  have  roller 
shades  in  the  main  room.  Frosted  glass  only  is  desirable 
by  day.  But  a  fair  way  to  settle  all  questions  of  privilege 
and  necessity  is  not  by  a  hole-and-corner  caucus  of  a  few, 
but  by  open  discussion  between  the  two  Boards. 


96  OPERATING   ROOM 

Plumbing. — The  scrub-up  stands  should  be  in  the 
main  room,  but  not  used  for  any  but  the  case  in  progress. 
Plumbing  for  these  is  a  vexed  question.  The  knee-swell 
is  an  excellent  thing  in  theory,  but  its  parts  have  not 
been  made  strong  enough  throughout  to  bear  the  strength 
necessary  to  open  the  valves.  The  foot-tread  has  worked 
out  best  in  most  cases.  There  should  be  only  one  faucet 
containing  mixed  hot  and  cold  water,  and  no  stoppers  in 
the  bottom,  since  the  hands  must  not  touch  any  but 
fresh-flowing  water.  It  is  imperative  to  have  an  easy 
but  always  reliable  adjustment  of  the  temperature  of  the 
water,  since  frozen  or  scalded  fingers  are  more  susceptible 
to  bichlorid-poisoning  and  less  capable  of  palpating  or 
holding  delicate  structures.  The  soap  should  drop  from 
jars  above  the  basin  by  means  of  a  push  with  the  elbow. 
The  nurse  cleaning  this  room  in  the  morning  should, 
therefore,  be  responsible  for  this  plumbing.  If  it  is  not 
in  order,  she  should  move  heaven  and  earth  to  get  it  in 
order  in  time  for  her  case.  When  repairs  are  in  progress 
anywhere  in  the  hospital  the  arrangements  should  not 
interfere  with  the  operating  room,  if  avoidable;  but  if 
the  hot  or  cold  water  must  be  cut  off,  the  head  nurse 
should  stipulate,  as  her  duty  to  her  cases,  at  what  hours 
it  may  best  be  done  per  schedule  for  the  day.  In  cases 
of  accident  some  one  should  hasten  to  turn  the  taps  in  the 
largest  tanks  before  it  is  cut  off  entirely.  When  the 
engineer  turns  it  on  again  after  the  repairs  the  inevitable 
sediment  should  not  be  allowed  to  flow  over  linen  or  deli- 
cate instruments. 

Faucets  are  installed  in  the  main  room  running  from 
the  sterilizers,  and  these  are  cleansed  with  disinfectants 
at  the  mouth  every  morning.  They  are  controlled  by 
foot-treads  or  knee-swells,  but  the  orderly  will  have 
polished  them.  They  supply  the  basins  for  rinsing 
gloved  hands,  for  washing  instruments  during  cases,  the 
irrigating  tank,  etc.  Faucets  for  ordinary  hot  and  cold 
unsterilized  water  are  also  needed  for  the  scrub-up 
stands. 


THE    MAIN    OPERATING    ROOM  97 

The  table  and  cabinets  should  be  made  of  nicalloy. 
It  is  substantial,  durable,  and  handsome,  besides  b^ing 
easily  cleaned.  To  establish  the  system  of  anesthetizing 
the  patient  on  the  table  and  wheeling  him  in  (to  save 
lifting  and  bruises)  such  a  table  should  have  a  very  broad 
pedestal  or  four  legs,  with  solid,  low,  broad  casters.  This 
table  should  be  selected  by  the  surgeons  of  the  staff  in 
committee,  each  trying  to  dispense  with  instead  of  demand 
a  number  of  unnecessary  fixtures.  All  handles  and  lexers 
for  Trendelenburg  should  be  controlled  by  the  anes- 
thetist, who  is  responsible  for  the  patient's  life.  He 
must  act  quickly.  The  old-fashioned  table  can  be  raised 
for  a  tall  surgeon  by  setting  it  in  four  equal  lengths  of 
stout  gas-pipe,  a  solid  bar  inside  each  leg,  running  up 
into  it  and  down  into  the  gas-pipe. 

There  should  be  stools  of  graded  heights,  shapes,  and 
lengths  for  the  assistants  at  a  case  requiring  Trendelen- 
burg, and  as  seats  for  the  anesthetists  or  nurses.  It 
should  be  an  understood  thing  that  a  nurse  might  be 
seated  for  a  few  moments  rather  than  stand  to  the  point 
of  exhaustion.  Her  internal  mechanism  demands  it. 
She  is  on  duty  in  the  operating  room  all  day.  The  sur- 
geon does  one  case  or  so  and  departs.  A  few  moments 
in  a  different  posture  plus  the  knowledge  that  one  has 
that  privilege  help  drive  away  fatigue. 

Electricity  is  used  in  many  forms.  The  engineer  is 
called  upon  to  demonstrate  and  teach  the  meaning  of 
the  following:  (a)  Direct  current  vs.  alternating  current; 
(b)  transformer;  (c)  rheostat;  (d)  switch;  (e)  watt;  (/) 
cystoscope,  etc.;  (g)  battery;  (h)  dry  cells;  (i)  storage; 
(j)  fuse;  (k)  motor;  (I)  dynamo;  (m)  cautery. 

Every  common  fact  about  electricity  must  be  known, 
so  that  the  pupils  may  handle  an  auriscope  or  a  cautery 
without  damaging  it.  Bulbs  should  not  be  screwed  in 
and  out  when  the  current  is  on,  for  fear  of  blowing  out 
t'he  fuse  and  putting  out  the  lights  on  one  line.  There 
should  be  chains  on  each  separate  high  light,  so  as  to 
enable  a  short  nurse  to  turn  off  all  but  one.  When  con- 


98  OPERATING   ROOM 

necting  up  an  electric  instrument  the  light  should  be 
tested,  then  turned  off,  until  the  adjustment  is  made. 

Electric  light  is  used  in  many  forms.  By  day  in  a 
dull  climate  electric  reflectors  are  used,  and  possess  many 
advantages  if  sufficiently  high  to  be  diffused,  especially 
in  old  institutions.  For  a  small  operating  room  in  an 
ordinary  town  service  six  powerful  100-watt  Tungstens 
make  an  excellent  night  light.  They  should  be  up  too 
high  to  burn  a  tall  surgeon's  head.  A  ground-glass  plate 
is  slung  beneath  them,  as  long  and  wide  as  the  whole 
chandelier,  making  no  strong  shadows  and  preventing 
dust  or  burns.  Again,  the  whole  ceiling  is  sometimes  of 
ground  glass  with  electric  lights  above  it  in  an  arched  or 
angled  attic,  where,  of  course,  only  the  electrician  can 
repair  and  exchange  bulbs  and  fixtures.  Still  better  is 
the  wonderful  Zeiss  light  which  is  generated  outside  the 
operating  room,  and  is  thrown  in  upon  a  large  number  of 
mirrors,  whence  it  falls  in  six  or  more  intensively  illumi- 
nating direct  pencils  upon  the  wound.  These  pencils  of 
light  do  not  cast  a  shadow  if  a  person  intercepts  them. 
The  outfit  is  expensive  and  at  present  impossible  to  ob- 
tain. Frosted  or  ground-glass  bulbs  are  necessary  for 
eye  work.  Every  sort  of  droplight,  to  be  held  by  hand  or 
on  a  flexible  metal  coil,  should  be  provided  and  wound 
with  sterile  gauze.  Patients  under  anesthesia  are  easily 
burned  by  lights  if  held  too  near  or  left  lying  on  them. 
The  "rolling  stock"  of  casters  and  rollers  should  be  so 
arranged  that  while  one  part  is  away  for  repairs,  there 
is  a  good  duplicate  in  its  place.  If  the  surgeon  wishes 
the  table  immobilized  the  casters  may  be  removed. 
Lock  rollers  are  a  good  device  for  this  purpose. 

A  silent  clock,  which  simply  throws  out  a  sheet  an- 
nouncing the  hour  and  minute  in  big  black  letters,  is  a 
very  pleasing  feature,  as  used  by  the  M.  E.  Hospital  in 
Brooklyn. 

Instrument  and  sponge  tables  should  have  only  one 
shelf,  so  as  to  save  the  nurse  her  clumsy  efforts  to  be 
aseptic  by  stooping,  winding  the  table  in  bichlorid  towels, 


THE    MAIN    OPERATING    ROOM  99 

and  struggling  with  shelf  covers  always  quite  too  large  or 
too  small.  Everything  to  be  used  for  the  patient  should 
be  on  a  level  with  his  body  as  he  lies  flat  on  the  table. 
You  know  about  how  long  floppy,  sloppy  sheets  remain 
"sterile"  below  the  level  of  one's  knee.  Operating  has 
been  so  speeded  up  and  simplified  of  late  that  fewer  mate- 
rials are  required.  Result,  the  scrubbed  nurse  has  fewer 
"impedimenta." 

In  a  private  house  the  hostess  has  at  her  foot,  under 
the  dining-room  table,  an  electric  push-button  to  sum- 
mon the  maid.  Similar  bells  ought  to  be  provided  for 
the  scrubbed  nurse.  If  the  unscrubbed  nurse  goes  out  to 
boil  up  an  instrument  she  need  not  stay  with  it.  She 
may  be  thus  summoned.  It  is  an  agonizing  and  monoto- 
nous feature  of  breaking  in  new  nurses  to  teach  them,  how 
to  know  where  to  be. 

Special  Table  Pads. — On  the  stretchers  and  table 
should  be  stout  pads  of  curled  hair  specially  bought  for 
the  purpose,  instead  of  folded  blankets  renewed  so  seldom 
as  to  be  thin  and  hard,  the  mother  of  a  hundred  bed- 
sores, especially  on  a  sick,  emaciated  patient  hanging  by 
the  coccyx  in  a  lithotomy  position  for  one-half  hour  or 
more. 

Tonsil  Table. — Throat  cases,  when  this  branch  of  the 
service  is  heavy,  should  have  a  special  table  on  which 
they  may  be  slowly  lifted  to  the  sitting  posture  while 
under  the  anesthetic.  The  heart  is  overdriven  by  ether 
and  weakened  by  chloroform,  so  the  patient  must  be 
very  cautiously  raised,  by  the  anesthetist  only,  to  the  opera- 
tor's fancy.  To  prevent  slipping,  a  seat  of  corrugated 
rubber  matting  is  provided. 

Cautery. — The  fixtures  for  the  cautery  should  be  in  the 
main  room,  at  a  proper  angle,  out  of  the  way  of  the  opera- 
tor. There  should  be  a  low  truck  of  heavy  pine  built, 
with  a  cover  and  solid  casters,  to  move  this  heavy  ap- 
paratus for  cleaning,  dusting,  and  cauterizing  purposes. 

Evacuating  Cysts. — Provision  must  be  made  for  re- 
moving in  a  cleanly  manner  the  contents  of  large  cysts  or 


100 


OPERATING   ROOM 


purulent  exudates.  The  operating  room  can  be  equipped 
with  a  large  aspirating  set,  capable  of  drawing  off  several 
gallons  of  cystic  fluid,  if  planned  from  the  engineering 
department  in  the  beginning.  The  smallest  size  of  "H.  D. 


To 


Fig.  15.— An  H.  D.  ejector. 


ejector"  does  the  work  most  efficiently  (Fig.  15).  It  is 
connected  with  high-pressure  steam  from  the  boiler-room 
and  discharges  to  the  atmosphere,  i.  e.,  the  outside  air. 
To  the  suction  opening  of  the  ejector  (i.  e.,  the  wall  of  the 


THE    MAIN    OPERATING    ROOM  101 

operating  room)  is  connected  a  rubber  tube  leading  to  a 
bottle  partly  filled  with  water.  From  this  bottle  another 
tube  goes  to  the  patient  (injection  of  aspirating  needle). 
The  fluid  is  started  off  by  opening  the  valve  at  the  wall. 
The  fluid  drawn  passes  into  the  water  in  the  bottle,  where 
it  remains,  while  any  air  that  may  'be  "djfaw'o; 'in  ao,  3ohe 
same  time  passes  on  through  the  ejector  to  the  atmosphere. 
When  the  air  is  all  expelled  the  cystij^f&iic?  follows; it  .to 
the  atmosphere  (i.  e.,  outside  the  building j. 

If  a  radium  outfit  is  owned  by  the  hospital  it  should 
be  kept  under  lock  and  key,  being  very  costly.  Its 
powers  are  measured  as  "emanations"  in  units,  called 
"mache  units,"  so  many  thousand  per  minute. 

Doors. — It  is  not  good  technic  for  the  surgeon  or  nurse 
to  pass  through  doors  after  scrubbing  up,  therefore  there 
should  be  a  row  of  four  stands  in  the  operating  room. 
Five  persons  may  be  needed,  but  the  two  nurses  need 
not  scrub  when  the  doctors  do  for  two  successive  cases. 
In  the  first  case  they  scrub  first.  Doors  should  be  pro- 
vided with  the  best  of  springs,  set  in  boxes  in  the  floor,  to 
fly  both  ways,  each  having  a  window  of  wired  glass,  about 
1  foot  long  and  2  feet  wide,  set  in  the  bottom  of  the  upper 
third  of  the  door,  flush  with  the  wood,  so  as  to  distinguish 
the  presence  of  anyone  on  the  opposite  side.  This  pre- 
vents costly  head-on  collisions,  and  should  be  uniform 
throughout  the  house,  where  swing-doors  are  needed,  in 
pantries  and  lavatories. 

Waste  receptacles  for  empty  covers  or  for  the  gory 
towels  of  a  tonsil  case,  if  they  must  be  in  the  room,  are 
metal  frames  on  casters,  with  a  bag  of  white  duck  or  can- 
vas inside,  freshly  laundered  and  changed  for  every  case. 

The  irrigating  tank  should  always  be  well  oiled  and  dust- 
less. 

Other  Rooms. — When  a  small  hospital  is  being  built  on 
a  limited  scale  its  fixtures  should  allow  of  alteration — e.  g., 
from  steam-  to  hot-water  heating  or  from  gas  to  electricity 
—but  the  Governors  should  plan  to  improve;  to  hitch 
their  wagon  to  a  star.  Some  companies  have  a  draught- 


102  OPERATING   ROOM 

ing  department  where  the  men  must  be  kept  busy,  there- 
fore for  a  small  sum  they  draught  and  make  blue-prints 
of  operating-room  suites  according  to  the  amount  of 
money  that  the  Board  has  to  spend. 

Off  the  main  room,  by  communicating  corridors, 
should  be  found — 

Instrument  cabinets. 

Anosthet;c  room. 

Store-rooms',   for  raw  goods,   sterilized   goods,   and 
dressings  in  wrappers. 

Workroom. 

Hopper  room. 

Sterilizing  room. 

Doctor's   dressing-room,   with    showers,  toilets,  and 
lockers. 

NURSES'  DRESSING-ROOM,  with  shower  and  toilets. 
This  much  is  imperative.  There  may  be,  besides, 
"dark"  and  "septic"  operating  rooms,  others  for  special 
work,  as  gynecology,  or  for  some  particular  surgeon. 
There  should  be  free  currents  of  air  and  powerful  light  in 
all,  and  not  any  germ-laden  holes  under  amphitheaters 
where  these  two  disinfecting  agents  cannot  penetrate. 
Where  is  the  hospital  that  has  provided  decent  conditions 
under  which  ALL  of  its  nurses  can  work? 

Preferably,  the  color  of  the  walls  is  soft  dull  green  with 
an  unglossed  finish  so  as  to  cast  no  high  lights.  Some 
operators  prefer  a  lusterless  pearl  gray,  but  it  is  generally 
conceded  that  green  is  more  restful.  There  must  not  be  a 
sharp  contrast  between  a  wound,  with  its  red  blood, 
brown-gloved  fingers,  and  white  gauze,  and  the  wall 
above,  to  which  the  surgeon  lifts  his  eyes  when  concen- 
trating his  attention  on  what  he  is  palpating. 

Elevators. — It  is  very  essential  to  be  near  the  elevators 
and  to  have  absolute  control  of  that  service.  Everything 
stops  when  a  patient  is  to  be  taken  up  or  down  except 
the  services  being  rendered  him.  For  fire-drill  the  ele- 
vator should  go  to  the  operating-room  floor  and  stay 
there.  In  the  equipment  for  fighting  fire  the  operating- 


THE    MAIN    OPERATING    ROOM  103 

room  floor  requires  extinguishers  and  hand-stretchers 
just  like  other  wings  or  floors,  especially  because  the  pa- 
tient is  unconscious.  Drill  should  consist  of  turning 
down  the  hand  grenades,  carrying  a  patient  down  the 
stairs  (if  the  elevator  shaft  were  in  flames),  closing  all  doors 
and  windows  to  prevent  draughts,  making  an  exit  down  the 
fire  escape  which  must  be  provided  SOT  this  suite,  providing 
wet  masks  and  blankets  for  all,  manipulating  the  wheeled 
stretchers  as  necessary,  and  definitely  appointing  each 
his  station. 


CHAPTER  VII 

THE   STERILIZING  ROOM 

THE  sterilizing  room  should  be  considered  under  the 
head  of  the  operating-room  suite,  though  in  some  very 
large  purely  surgical  institutions  it  is  conducted  separately 
by  a  graduate  nurse  on  account  of  the  extensive,  accurate 
work  involved,  though  the  obligations  incurred  have  to 
be  rendered  to  such  an  immediate  neighbor  that  friction 
may  occur  where  mistakes  are  made  in  the  former.  The 
sterilizing  room  should  be  cut  off  from  the  rest  of  the  suite 
by  a  shaft  of  open  air,  especially  easy  when  there  is  a 
loggia  or  balcony  below  and  nothing  above  but  roof  or 
another  loggia.  The  cold  air  coming  up  the  shaft  causes 
a  condensation  of  vapor  which  otherwise  would  raise  the 
temperature  of  the  rooms  and  depress  the  vitality  of  the 
workers.  Besides,  cutting  down  this  vapor  saves  the 
walls  of  the  suite  enormously  from  chipping  of  paint, 
falling  plaster,  etc.  Cooled  air  can  be  forced  up  a  flue 
from  the  engineering  department,  pushing  out  the  vapor- 
laden  atmosphere,  while  the  air-shaft,  lying  between 
two  solid  walls  and  connected  with  the  rest  of  the  suite 
by  stout  swing-doors,  need  not  be  so  wide  that  a  nurse 
could  grow  chilled  passing  through.  If  it  is  bounded  on 
the  top  by  the  sky  it  should  be  protected  from  rain  and 
snow.  The  gangway  should  have  high  balustrades. 

The  sterilizers  for  water  should  both  contain  a  cold  coil, 
so  that,  no  matter  which  one  is  the  hotter  or  the  lower,  it 
can  be  cooled  and  used  in  emergency.  Where  this  has 
been  installed  the  supervisor  states  emphatically  that  it 
saves  both  time  and  anxiety.  Each  has  two  taps,  one 
on  a  pipe  into  the  operating  room. 

The  sterilizers  must  be  run  every  day,  no  matter  whether 
there  is  operating  or  not.  They  should  be  large  enough  to 

104 


THE    STERILIZING    ROOM  105 

furnish  water  for  twenty-four  hours  of  steady  operating 
— imagining  a  frightful  contingency,  such  as  a  railroad 
wreck.  There  should  be  no  extravagance,  but  there 
should  always  be  a  liberal  supply  of  all  those  materials 
that  it  is  impossible  to  prepare  in  a  moment — cold  sterile 
water,  towels,  gowns,  and  dressings.  In  small  hospitals 
the  steam  is  generated  by  gas,  but  these  fixtures  should 
be  put  in  so  as  to  be  interchangeable  with  steam.  Damp 
dressings  are  not  sterile. 

Nickel  is  the  best-looking  material,  cleaned  when 
cool  with  any  good  nickel  polish.  The  suffocating  smell 
from  brass  polish  makes  other  metals  undesirable.  The 
taps  from  the  sterilizers  into  the  operating  room,  as 
well  as  those  in  the  inner  room,  should  be  cleansed  with 
green  soap  and  a  brush,  then  alcohol,  then  rinsed  after  the 
orderly  polishes  them.  The  body  of  the  sterilizer  may  be 
set  quite  high,  in  order  to  obtain  pressure  on  the  operating- 
room  side  at  delivery.  It  is  a  sterile  receptacle  which  is 
brought  to  them  always  to  be  filled,  and  should  be  covered 
with  a  sterile  towel  if  sent  to  the  wards.  Even  though  we 
know  it  is  filtered  and  boiled,  it  must  be  observed  as  to 
color,  cleanliness,  etc.,  daily. 

Filters. — There  should  be  two  filters  for  each  set  of 
sterilizers,  one  in  use  and  one  being  cleansed  and  aired. 
Each  nurse  must  learn  how  to  run  all  of  the  sterilizers, 
since  she  has  to  do  that  work,  not  the  orderly.  A  nurse 
should  not  pass  up  the  care  of  this  part  of  the  equipment, 
since  it  demands  a  conscience  and  causes  no  fatigue.  It 
requires  some  of  the  qualities  of  honesty  and  reliability 
that  her  diploma  stands  for. 

Sterilizers  are  best  placed  on  a  solid  pedestal  with 
exposed  fixtures  and  in  the  center  of  the  room,  not 
close  to  a  wall.  It  is  much  easier  to  repair  them.  The 
utensil  sterilizer  should  stand  very  low,  so  as  to  have 
no  strain  on  a  nurse's  arm  when  she  lifts  out  basins. 
Much  more  important  is  the  height  of  the  instru- 
ment boiler,  which  throws  live  steam  in  the  face  in 
most  cases. 


106  OPERATING    ROOM 

Engineer's  Instructions. — The  engineer's  services  are 
required  in  instructing  pupils  in  the  mysteries  of  water 
and  steam,  showing  them  the  make-up  of  a  valve,  a 
water-jacket,  a  coil,  a  hydraulic  lift.  In  their  minds 
should  be  firmly  fixed  a  diagram  of  the  journey  made  by 
the  steam  so  as  to  prevent  future  explosions,  wet  dressings, 
etc.  One  valve  cannot  be  opened  without  affecting  the 
whole  system,  and  to  open  a  series  of  valves  in  the  wrong 
order  may  wreck  the  whole  equipment. 

A  certain  specialist  in  sterilization  has  declared  that 
the  live  steam  should  circulate  directly  through  the 
chamber  of  the  dressing  sterilizers  all  the  time,  and  he 
has  had  the  autoclave  altered  by  the  addition  of  a  small 
vent  at  the  front  on  the  lower  edge  with  a  stop-cock. 
When  the  gauze  shows  15  pounds'  pressure,  the  stop-cock 
is  opened  so  as  to  allow  a  tiny  stream  of  live  steam  to  escape 
with  a  shrill,  whistling  sound.  This  must  be  continuous 
during  the  half-hour.  Besides,  the  theory  is  advanced 
that  sterilization  of  a  test-tube  with  only  one  open  end 
is  imperfect,  and  that  the  live  steam  must  pass  through 
them,  with  the  result  that  all  gauze  packing  is  done  up 
in  glass  cylinders  with  two  open  ends.  There  should  be 
two  dressing  sterilizers  at  least,  so  that  if  one  is  out  of 
order  or  if  there  is  a  heavy  rush  of  work  there  need  be  no 
loss  of  time.  Formerly  drums  for  autoclaves  were  made 
so  large  that  the  nurses  handling  them  were  nearly  killed, 
especially  as  orderlies  are  very  ubiquitous.  The  small 
long  autoclave,  with  drums  about  16  inches  in  diameter, 
is  found  to  be  a  great  improvement.  The  round  dressing 
sterilizer  is  best  for  holding  flasks  of  saline.  In  packing 
drums  what  is  needed  first  is  put  in  last.  The  nurse 
packing  it  then  drops  in  a  slip  bearing  her  own  signature, 
so  that  if  it  holds  any  errors  she  will  be  reprimanded 
directly.  This  positively  reduces  the  number  of  errors 
in  packing.  A  drum  is  packed  with  the  goods  neces- 
sary for  a  certain  kind  of  case,  but,  of  course,  the  main 
supply  of  sterile  dressings  is  also  drawn  on.  If  drums 
containing  sterile  goods  stood  idle  a  much  larger  outlay  of 


THE    STERILIZING    BOOM  107 

linen  would  be  required.  A  specially  designed  low  truck 
is  used  to  draw  the  drums  into  the  operating  room. 

In  a  busy  time,  in  order  to  let  the  day  nurses  off  earlier, 
the  night  staff  should  run  the  sterilizers,  either  before  the 
patients  go  to  sleep  or  after  they  waken.  The  fact  results 
in  the  condition  of  having  only  the  roof  above  that  few  if 
any  could  hear  this.  When  the  sterilizing  room  is  walled 
off  by  an  open-air  shaft  it  may  be  operated  during  cases 
without  disturbing  the  surgeons. 

Tests  for  Complete  Sterilization. — Several  tests  for  per- 
fect sterilization  are  to  be  had.  There  is  a  small  tube 
which  opens  only  when  the  right  degree  of  heat  is  at- 
tained, and  which  is  wrapped  in  a  double  muslin  cover 
in  the  center  of  all  the  bundles  or  in  the  heart  of  the 
middle  drum.  When  they  are  kept  at  15  pounds  for  one- 
half  hour  and  opened  up,  the  fact  of  this  tiny  test-tube 
being  open  is  proof  that  the  sterilization  was  correctly 
done.  Other  tests  are  made  with  actual  bacteria  from 
cultures  or  smears.  All  gauze  and  cotton  should  be  put 
up  in  double  covers  of  stout  muslin  and  used  in  the  order 
of  date  of  sterilizing.  Fractional  sterilization  means  for 
three  days  in  succession,  one-half  hour  at  a  time,  to  kill 
the  spores.  Tubes  are  closed  with  plugs  of  gauze  and 
cotton,  then  wrapped  in  double  muslin  covers.  This 
responds  to  the  most  accurate  bacteriologic  tests.  lodo- 
form  must  be  used  occasionally  and  is  sterilized  in  brown 
jars  or  brown  glass  tubes.  To  have  covers  plenty  large 
enough  to  tuck  in  tightly  (placing  the  contents  diagonally) 
will  dispense  with  a  great  deal  of  soreness  in  fingers  useful 
for  better  purposes.  A  tailor's  thimble  with  the  end 
open  helps  in  putting  in  pins.  Filter-paper  should  be 
sterilized  before  making  saline. 

Distillation. — The  sterilizing  room  is  the  proper  place 
for  distillation.  The  little  plant  for  this  can  be  installed 
near  the  corner  with  two  faucets,  one  for  the  inner  room 
and  one  for  the  operating  room,  the  latter  pipe  running 
through  the  wall  or  isolated  on  the  deal  counter  in  the 
middle  of  the  room.  Distillation  is  imperative  for  cer- 


108  OPERATING   ROOM 

tain  uses  in  every  department  of  the  hospital.  A  small 
outfit,  kept  going  steadily,  produces  enough  at  a  very 
slight  cost.  Under  certain  climatic  and  topographic  con- 
ditions even  distilled  water  will  make  a  cloudy  saline 
solution,  which,  however,  disappears  usually  on  the  ap- 
plication of  heat.  Distilled  water  should  be  drawn  off 
into  sterile  containers  and  sterilized  again,  like  saline, 
before  using,  since  what  is  on  the  inside  surface  of  the 
container  itself  may  develop  life,  with  the  aid  of  the 
water,  otherwise. 

This  room,  which  ought  in  one  sense  to  be  the  cleanest 
of  the  whole  suite,  where  utensils,  linen  dressings,  and 
instruments  are  made  ready  to  approach  a  wound,  is  not 
a  proper  place  to  scrub  up  in  or  to  wash  out  bloody  linen 
or  pus.  The  former  should  be  done  by  the  nurse  in  the 
main  room.  The  latter  should  be  done  in  the  hopper 
room;  also  the  cleaning  of  instruments.  On  account  of 
this  room  being  cut  -off  by  a  cold-air  shaft  nothing  but 
sterilization  should  be  done  there  in  justice  to  the 
nurses. 

This  room  needs  a  large  clock,  kept  in  perfect  condition, 
to  time  the  water  and  dressings  by  the  code  drawn  up  by 
the  house  pathologist  and  O.  K.'d  by  the  surgeons.  To 
a  busy  nurse,  alone  in  an  outer  room,  an  alarm  clock  set  to 
go  off  at  certain  times  is  a  priceless  boon. 

The  utensil  and  instrument  sterilizers  should  both  be 
operated  by  a  hydraulic  lift,  and  a  special  pair  of  clamps, 
kept  cleanly  boiled,  in  the  end  of  the  latter  to  move  the 
basins  in  the  former,  which  are  put  in  face  down,  so  that 
they  could  be  lifted  out  by  hand  if  necessary. 

A  glove  sterilizer  where  all  the  gloves  are  boiled  separate 
from  sharp-pointed  instruments  is  a  great  luxury.  This 
should  be  lined  with  a  muslin  bag  to  prevent  the  gloves 
from  touching  the  metal.  A  thin  layer  of  white  muslin 
in  any  boiler  aids  one  in  counting  all  the  instruments. 
The  glove  rack,  like  a  hat-tree,  thickly  studded  with 
finger-shaped  prongs,  a  glove  to  a  prong,  stands  here. 
The  gloves  must  not  be  laid  on  a  radiator. 


THE    STERILIZING    ROOM  109 

Printed  Instructions. — There  should  be  printed  codes 
of  instructions  on  the  following: 

(1)  At  what  regular  dates  to  have  all  the  equipment 
inspected  by  the  manufacturers'  agent    and  overhauled, 
with  their  address,  for  the  purpose  of  getting  emergency 
repairs  quickly. 

(2)  Directions  how  to  act  in  emergencies;  e.  g.,  flooding 
of  the  utensil  sterilizers,  leaks,  etc. 

(3)  Directions  how  to  run  each  and  every  piece. 
There  should  always  be  at  least  two  persons  on  duty 

who  understand  the  running  of  this  apparatus.  But 
printed  rules  are  of  no  use  until  the  supervisor  has  de- 
monstrated every  feature  to  her  scholar  and  has  seen  the 
scholar  do  the  same  thing  correctly  and  often  enough  to 
be  automatic.  It  is  wise  in  buying  to  secure  a  guarantee 
for  all  repairs  for  as  many  years  as  possible. 

Infections  Due  to  This  Department. — Not  all  infec- 
tions are  traceable  to  the  sterilizing  room,  if  indeed,  any 
are.  But  if  a  hernia  becomes  infected,  which  is  a  great 
disgrace,  every  means  must  be  employed  to  ferret  out  the 
cause.  The  surgeon  and  the  pathologist  work  'here  hand- 
in-hand,  co-operating  with  the  supervisor.  Every  avenue 
is  opened  to  investigation.  There  is  generally  one  definite 
cause  and  that  not  far  to  seek.  If  a  series  of  infections 
occur,  every  gown  and  glove  should  be  marked,  traced, 
and  set  aside,  as  well  as  dressing-covers,  basins,  etc. 
The  surgeon  should  relate  the  nature  of  all  the  cases  he 
has  handled  elsewhere.  Cultures  taken  on  all  hands, 
examination  of  new  catgut,  complete  quarantine  of  dirty 
cases  on  the  wards,  cultures  of  the  infected  wound,  ex- 
amination of  throats  and  nasal  passages,  a  general  wash- 
ing of  heads,  etc.,  will  lead  to  ultimate  discovery  and  pre- 
vention. When  cleaning  up  after  a  dirty  case  the  nurse 
should  scrape  her  short  finger-nails  across  a  cake  of  soap 
first. 

Safety  Devices. — The  less  complex  the  equipment,  the 
more  nearly  certain  the  supervisor  can  be  that  her  pupils 
are  manipulating  it  properly  when  her  back  is  turned. 


110  OPERATING   ROOM 

All  apparatus  should  have  safety  devices  to  prevent  ex- 
plosions. All  the  sterilizers  should  be  controlled  entirely 
by  a  lever  in  front.  All  steam  fittings  and  plumbing 
should  be  quite  far  out  from  the  wall  to  permit  perfect 
polishing,  dusting,  painting,  and  repairs. 

The  blanket  warmer  stands  in  the  sterilizing  room, 
being  heated  by  steam  in  a  jacket.  When  a  nurse  goes 
for  a  blanket  she  should  take  one  to  leave  in  place  of  it, 
and  a  Turkish  towel  to  wrap  around  the  hot  one. 

Electricity  for  sterilizing  is  neat,  but  a  cause  of  iorget- 
fulness  and  destruction,  therefore  not  to  be  recom- 
mended. Nurses  have  much  on  their  minds  and  should 
not  have  to  face  this  extra  care. 

Flooring. — On  account  of  the  immense  amount  of 
plumbing  and  the  condensation  of  vapor  the  floor  becomes 
very  slippery,  and  a  nurse  in  a  hurry  may  sustain  a  bad 
fall.  The  lower  floor  should  be  impervious  to  moisture, 
but  it  may  be  laid  suitably  with  strips  of  cork  or  corru- 
gated rubber  matting.  "Safety  first." 


CHAPTER  VIII 

THE  WORKROOMS 

THE  room  in  which  dressings,  plaster  bandages,  and  all 
packages  are  made  should  be  large,  light,  and  airy  to 
preserve  the  nurses'  health  and  produce  well-done  tasks. 
Each  nurse — head,  scrubbed,  anesthetic,  and  junior — 
should  have  her  fixed  place  to  work  at,  but  if  there  are 
fewer  nurses  each  kind  of  work  should  have  its  place  and 
the  nurse  should  go  to  it  when  ready.  The  windows 
should  be  of  a  very  flexible  adjustment,  to  admit  air  in 
large  or  small  quantities  without  draughts.  Along  the 
inner  wall  there  should  be  numerous  cupboards  to  keep 
the  goods  in  process  of  making  only,  as  distinguished 
from  the  goods  in  bulk  and  those  in  covers  or  sterilized  in 
reserve.  The  head  nurse  should  have  a  solid  well-built 
desk,  with  locked  drawers,  for  the  operating  register, 
nurses'  record  cards,  and  similar  data  not  to  be  handled 
by  others.  Here  she  can  write  out  her  records  when  the 
day  is  done.  An  electric  desk  lamp  should  be  provided 
for  night  work.  A  spindle  occupies  a  prominent  place 
here,  holding  all  the  memoranda  of  the  staff,  and  cleaned 
off  daily.  In  the  center  of  the  room  stands  a  long,  low 
deal  counter,  always  spotlessly  clean,  with  stools  or 
heavy  solid  kitchen  chairs  of  assorted  heights  (from  the 
floor),  so  arranged  that  the  knees  may  go  under  the 
counter  and  the  feet  find  rest  on  a  bar  down  the  center 
at  the  floor.  Of  all  the  work  in  the  hospital  the  least 
provision  has  ever  been  made  for  what  goes  on  behind 
the  scenes  in  an  operating  room.  Footstools  and  step- 
ladders  are  to  be  provided  to  reach  the  top  shelves  of  cup- 
boards, all  of  the  latter  bearing  lists  on  the  doors  showing 
what  they  must  contain.  Stools  should  have  holes  in  the 

in 


112  OPERATING   ROOM 

seat  to  lift  them  by,  and,  like  the  aseptic  operating-room 
furniture,  all  should  have  rubber  feet.  A  sewing-machine 
kept  in  good  condition  should  stand  with  its  left-hand  end 
at  a  window,  and  not  far  away  an  ironing  board  and  an 
electric  iron,  none  of  these  to  be  used  for  the  nurses' 
personal  benefit,  of  course,  but  for  covers  and  other  special 
articles.  Work  cannot  be  efficient  if  done  on  the  corner 
of  a  crowded  table  or  put  away  helter  skelter  in  one  com- 
mon cupboard. 

(1)  Do  all  one  kind  of  work  at  one  time. 

(2)  Have  a  place  for  everything  and  always  restore  it 
immediately  to  its  place.     Do  not  wait  one  moment. 

(3)  Clean  everything  away  at  night  in  such  a  manner 
that  it  can  be  resumed  at  once  in  the  morning. 

(4)  Avoid  continued  conversation  and  do  not  become 
familiar  and  overfriendly. 

(5)  Do 'not  make  the  workroom  a  scene  of  visiting  by 
convalescents,  friends,  or  physicians. 

(6)  Dust  the  workroom  morning  and  evenings  on  ac- 
count of  the  fluffy  dust  off  all  goods. 

(7)  Mark   off   the   deal   table   in   yards,    halves,    and 
quarters   at   each   nurse's   station,  and   out   in   front  of 
her  the   various   sizes   of   compresses,   sponges,  etc.,  in 
squares. 

(8)  Keep  here  various  sets  of  labels  and  nurses'  signa- 
tures to  put  on  or  drop  into  special  packages,  i.  e.t  infu- 
sion sets,  drums,  etc. 

(9)  Allow  no  loafing,  but  arrange  that  those  fatigued  by 
standing  may  rest,  sitting  with  their  feet  off  the  floor. 

(10)  Preserve  all  introductory  steps  toward  asepsis  in 
the  workroom,  frequent  washing  of  the  hands,  etc. 

(11)  For  making  special  dressings — i.  e.,  boroglycerite 
tampons,  iodoform  gauze,  etc. — use  a  thick  glass  slab  on 
the  deal  work  table. 

(12)  The  floor  should  be  of  narrow  hard-wood  strips, 
which  have  more  resilience  than  tiling.     This  applies  to 
the   store-rooms,    dressing-rooms,    etc.,    but   not   to   the 
main  operating  room  or  sterilizing  room,  of  course. 


THE    WORKROOMS  113 

(13)  Keep  plenty  of  light  supplied  on  dull  days  when 
work  of  a  fine,  close,  or  arduous  nature  is  in  progress, 
but  fine  the  person  a  penny  who  leaves  a  light  on  when  it 
is  not  in  use,  and  devote  the  proceeds  toward  the  purchase 
of  some  luxury. 

(14)  A  set  of  teacups  and  a  tea  urn  or  coffee  percolator 
make  largely  for  content  and  good  work  so  long  as  these 
tired  nurses  honorably  avoid  taking  advantage  of  the 
privilege,  and  do  not  keep  their  one  single  luxury  too 
much  in  evidence,  especially  when  a  patient  is  about  to 
be  anesthetized. 

(15)  The  nurses  should  call  one  another  by  the  same 
titles  used  in  class,  "Miss  A.,  Miss  B.,  etc.,  etc." 

(16)  There  should  always  be  some  nurse  on  duty  and 
so  stationed  that  she  may  see  visitors,  answer  queries, 
and  present  a  neat  appearance.     While  there  is  linen  to 
wash  out,  etc.,  there  should  be  no  fewer  than  two  on 
duty. 

Hopper  Room. — The  hopper  room  should  contain  a 
high  sink,  several  hoppers,  and  a  set  of  tubs  for  rubbing 
out  blood,  feces  or  stains,  and  for  disinfecting..  When 
the  tubs  have  plugs  at  the  bottom  it  is  not  necessary  to 
to  have  plugs  in  the  hoppers.  But  in  all  fine  drains  are 
necessary  to  prevent  the  passage  of  cotton  into  the 
plumbing  system.  The  hopper  room  should  be  con- 
stantly aired.  Arrangements  are  necessary  to  notify  the 
laundry  when  wet  linen  is  sent  down,  so  that  it  may  be 
soaked  again  immediately,  therefore  a  loud  electric  bell 
at  the  foot  of  the  chute  is  wired  to  the  operating-room 
floor  for  that  purpose.  The  chute  opens  in  the  hopper 
room,  and  the  button  beside  it  is  not  rung  for  dry  wash. 
One  wall  is  lined  with  cupboards  for  mops,  floor  brushes, 
dusting-cloths,  basins,  etc.,  all  of  which  are  washed, 
boiled,  or  sunned  before  being  put  away.  A  set  of  three 
rings  attached  to  screws  arranged  vertically  on  the  walls 
makes  an  excellent  broom  or  mop-holder.  The  cupboards 
should  have  only  wire-screen  doors  in  order  to  maintain 
a  good  airing  system. 

8 


CHAPTER  IX 

ASEPSIS 

ASEPSIS  means  the  absence  of  pathogenic  micro- 
organisms; in  other  words,  freedom  from  dangerous 
germs. 

Methods  of  Carrying  Out  Asepsis.— In  the  nurses'  text- 
books on  bacteriology  is  given  a  history  of  all  the  efforts 
of  modern  times  to  reduce  operative  surgery  to  a  harm- 
less process  by  excluding  all  dangerous  germs  from  the 
field.  Results  are  now  almost  as  good  as  one  can  hope 
for,  but,  while  scientists  have  almost  reached  their  goal, 
the  nurse  must  daily  make  the  same  tremendous  effort  and 
maintain  the  same  ceaseless  vigilance  in  running  steriliz- 
ers or  boiling  instruments;  in  unfolding  sterile  goods  or 
"setting  up"  for  operation.  Everything  must  be  done 
"with  a  conscience."  In  past  times  when  a  superin- 
tendent wished  to  let  a  nurse  down  easy  who  was  old  or 
homely  or  hateful  she  generally  described  her  as  "con- 
scientious," but  nobody  can  really  tell  whether  a  nurse  is 
conscientious  or  not  without  observing  her  every  day, 
unless  perhaps  it  be  a  very  intelligent  patient  or  the  other 
nurse  whose  work  dovetails  into  hers.  The  foundations 
of  asepsis  are  "conscience"  and  intelligence.  A  head 
nurse  must  early  drill  her  pupil  into  good  habits  of  body, 
just  like  calisthenics,  so  as  not  to  bump  into  sterile 
tables,  until  she  can  move  about  the  operating  room  with 
ease  and  safety.  A  pupil  should  on  this  service  act  as  if 
she  had  a  set  of  delicate  antennae  all  over  her  person, 
warning  her  when  she  approaches  "red-hot" — i.  e.,  sterile 
— goods.  She  must  think  with  her  elbows,  the  corners  of 
her  apron,  or  the  peak  of  her  cap,  knowing  how  wide  a 
margin  of  safety  they  require  to  keep  away  from  sterile 
things  in  every  direction — above,  below,  or  at  the  side. 

114 


ASEPSIS  115 

•  Then,  too,  in  regard  to  boiling  instruments  or  running 
the  sterilizer,  a  head  nurse  cannot  leave  the  ordinary  un- 
mechanical  minded  pupil  alone  with  such  complicated 
apparatus  until  she  has  absolutely  mastered  it,  even  after 
which  she  should  quietly  take  note  of  the  steps  employed 
by  the  pupil  to  time  herself  in  running  it. 

Damp  Dressings. — If  the  dressings  are  damp  the 
pupil  should  bravely  confess  it,  dry  them  on  a  radiator 
through  and  through,  and  take  her  medicine  by  staying 
on  after  hours  to  resterilize  them,  having  learned  where  she 
made  her  mistake.  It  must  be  made  very  impressive 
on  these  pupils'  minds  that  dressings  not  sterilized  may 
convey  death  to  a  patient  as  surely  as  a  dose  of  prussic 
acid,  and  that  dampness  means  no  sterilization;  worse 
than  that,  a  gateway  through  the  moist  covers  favorable 
to  the  entrance  of  disease-bearing  bacteria.  In  the 
operating-room  atmosphere  pupils  are  prone  to  forget  the 
living  human  being  in  the  wards  below  for  whom  they 
exist.  It  is  very  wholesome,  therefore,  to  have  the 
operating-room  staff  relieve  on  the  wards  at  regular 
times  to  observe  the  cases  they  have  seen  operated  on, 
and  to  acquire  an  interest  in  the  cases  coming  up  to  them. 
This  takes  away  the  danger  of  simply  rushing  goods 
through  on  a  time-limit  without  caring  whether  they  are 
done  properly  or  not.  By  the  way,  when  the  pupils  go 
to  the  wards  to  relieve  they  should  display  some  skill  in 
readjusting  themselves  to  those  conditions  instead  of 
loafing  and  putting  on  superior  airs. 

Dressings,  gloves,  gowns,  and  towels  are  now  steril- 
ized once  a  day  for  three  days-  in  succession  in  order  to 
kill  not  only  the. germs  but  their  spores.  This  necessi- 
tates a  careful  planning  of  cupboards  and  closets  with 
wire  doors  for  ventilation,  so  that  what  is  finished  (the 
third  time)  cannot  be  confused  with  what  is  run  through 
only  once.  It  defeats  our  object  to  let  the  unfinished 
goods  lie  around  carelessly,  exposed  on  dusty  tables  or 
open  shelves  or  in  a  damp  room.  Whether  put  up  in 
drums  or  loose  in  the  older  style  sterilizer,  they  should 


116  OPERATING   ROOM 

be  marked,  "Sterilized  once,  Jan.  10th,"  "Sterilized  twice, 
Jan.  llth,"  and  "Sterilized  three  times,  Jan.  12th." 

Mechanical  Cleanliness. — The  greatest  care  must  be 
taken  to  procure  ordinary  mechanical  cleanliness  com- 
bined with  sterilization.  One  must  keep  away  all  dust, 
K.  Y.  lubricant,  liquids,  particles,  etc.,  from  the  goods  to 
be  placed  around  a  wound.  It  is  a  great  mistake  to 
thrust  a  dusty  bundle  into  a  sterilizer  thinking  that  will 
cure  all  defects.  While  operating,  emptied  covers  should 
be  collected  in  a  basket  and  promptly  sorted. 

Covers  for  dressings  are  made  of  stout  unbleached 
muslin  of  two  thicknesses,  with  the  name  of  the  con- 
tents written  or  stencilled  in  ink  on  the  outside.  These 
covers  are  carefully  stitched  around  three  sides  on  the 
wrong  side,  then  finished  on  the  right  by  turning  and 
closing,  and  present  a  good  appearance.  The  oftener 
they  are  washed,  the  longer  they  stand  the  heat.  It  has 
been  proved  by  bacteriologists  that  a  germ  cannot  travel 
through  a  double  cover  within  a  reasonable  time.  A 
cover  12  inches  square  will  hold  six  ordinary  flat  4-inch 
gauze  compresses,  with  plenty  of  room  to  open  the  pack- 
age aseptically,  i.  e.,  without  touching  the  inside  of  it. 
The  gauze  is  laid  diagonally  in  the  center,  the  first  corner, 
then  the  two  sides  laid  over,  then  the  fourth  corner  folded 
over,  tucked  in  flatly  and  deeply,  then  fastened  with 
two  pins,  each  buried  with  one  insertion. 

The  nurse  can  here  be  shown  a  little  point  in  preserv- 
ing asepsis.  If  a  pin  were  put  in  in  the  usual  way,  with 
two  or  three  jabs,  a  person  handling  that  bundle  in  the 
workroom  might  contaminate  the  exposed  part  of  the 
pin  with  germs  from  the  floor  or  the  finger-nails.  When 
the  pin  is  pulled  out  this  would  be  carried  inside  the 
cover  directly  to  a  compress,  which,  being  used  to  sponge 
vigorously,  carries  the  same  germ  deep  into  the  wound. 
A  little  red  ink  or  blue  chalk  would  represent  such  germs 
on  the  exposed  part  of  the  pin. 

Caps,  Masks,  Glasses.— The  pupils  must  wear  cool, 
tight-fitting  caps  of  sheer  lawn  covering  their  hair  en- 


ASEPSIS  117 

tirely  to  prevent  dandruff  from  falling  on  the  sterile  table. 
They  should  adhere  strictly  to  this,  no  matter  how  try- 
ing it  may  be  to  their  persoual  appearance.  They  must 
also  stand  erect,  and  not  have  any  more  of  their  person 
than  can  be  helped  over  the  table.  In  a  recent  case  of 
intravenous  infusion  the  arm  was  badly  infected  with  a 
persistent  condition  locally  which  did  not  proceed  from 
the  saline.  There  was  a  .moderate  purulent  discharge, 
followed  by  a  ringworm  appearance,  which  could  only  be 
accounted  for  by  the  possibility  of  dandruff,  since  three 
surgeons  had  their  capless  heads  together  over  the  arm, 
looking  for  the  small  vein.  Ringworm  treatment  finally 
cleared  it  up  after  ten  weeks'  duration.  By  co-opera- 
tion between  operating  room  and  laboratory  the  pupils 
learn  what  scarf-skin  or  dandruff  looks  like,  or  what 
effects  either  produces  when  injected  into  a  guinea-pig. 
Besides,  germs  abound  in  the  hair,  which  cannot  be  treated 
like  the  hands,  therefore  it  should  be  kept  very  closely 
confined.  To  the  good  surgeon,  good  on  the  basis  of 
working  for  the  best  results,  the  best-looking  nurse  is  the 
one  dressed  most  becomingly  for  her  task.  The  operating 
room  is  a  good  place  to  study  character,  where  people  are 
stripped  of  some  of  their  masks,  and,  working  at  high 
tension  and  unable  to  keep  on  guard,  show  themselves  in 
their  true  colors. 

The  surgeons'  caps  and  masks  should  be  laid  on  the 
scrub-up  stands,  so  that  they  may  don  them  imme- 
diately after  changing  from  their  street  clothes  to  their 
wash  suits,  but  before  they  scrub  and  before  they  don  their 
gowns.  It  is  bad  technic  to  have  a  nurse  put  one's  cap 
and  mask  on  after  the  gown  and  shake  dandruff  down  on 
it.  The  caps  should  cover  the  hair  completely,  but  be 
of  light  goods  to  minimize  perspiration.  Perspiration  is 
of  a  very  dangerous  nature,  containing,  as  it  is  an  elimi- 
native  agent,  all  the  poisons  of  the  body.  The  operating 
room  must  be  quite  warm  for  the  patient's  sake,  and  high 
tension  in  work  makes  most  men  perspire  profusely. 
The  pupil  who  acts  as  "dirty  nurse,"  or  "unscrubbed," 


118  OPERATING   ROOM 

must  move  quickly  when  a  man  perspires.  She  winds  a 
clean  hand  towel,  not  a  dressing  towel,  around  her  right 
wrist  so  as  to  leave  no  floating  ends,  and  as  the  surgeon 
leans  his  head  away  from  the  table,  out  of  line  with  his 
body,  she  very  firmly  and  slowly  wipes,  just  as  she  dries 
her  own  face,  with  deep  systematic  strokes,  not  with  faint 
tickling  dabs  (see  Fig.  3).  The  operator's  glasses  must 
not  be  disturbed,  since  he  prefers  to  set  them  himself, 
but  his  hands  are  in  the  wound.  Blood  on  the  glasses 
necessitates  their  removal  and  return  after  being  washed 
with  cold  water.  It  is  an  awful  catastrophe  to  drop  them 
or  break  them  with  hot  water,  because  that  virtually 
blinds  some  men.  Boric  acid  and  argyrol  (25  per  cent.) 
should  be  kept  in  case  of  chances  of  infection  from  blood 
or  pus. 

Tests  by  Cultures. — Cultures  should  be  taken  from  the 
nails  of  tfye  surgeons  and  nurses  after  scrubbing  up  at 
irregular  intervals.  Some  of  the  results  are  very  appalling! 
Some  hospitals  have  a  "test  day,"  when  the  pathologist 
comes  to  the  operating  room  and  takes  cultures  from  all 
sorts  of  places — the  door-knobs,  saline  solution,  the  hands 
of  the  staff,  the  buttons  on  the  light  switches,  the  dress- 
ings, etc. — to  show  the  actual  existence  of  bacteria.  The 
operating  room  is  a  sort  of  clearing-house  for  bacteria  in 
the  hospital,  anyway.  Other  institutions  have  a  "moni- 
tor," a  junior  intern  probably,  appointed  to  come  unex- 
pectedly to  watch  for  breaks  in  technic,  to  see  if  anyone 
who  is  at  all  concerned  with  the  wound  touches  any- 
thing unsterile  or  if  any  sterile  goods  become  contami- 
nated. One  set  of  pupils  receive  sufficient  instruction  from 
one  set  of  cultures;  i.  e.,  these  visits  can  be  made  once 
each  quarter,  during  the  senior's  last  and  the  junior's 
earlier  weeks. 

There  is  a  great  inconsistency  in  the  preparation ,  of 
various  kinds  of  goods  by  sterilization.  The  time  limit 
and  the  number  of  pounds  of  pressure  vary  for  rubber 
gloves,  gauze,  and  iodoform  packing.  Then,  too,  in  some 
institutions  gloves  are  boiled.  Sometimes  sharp-edged 


ASEPSIS  119 

instruments  are  merely  soaked  in  pure  carbolic  acid  and 
alcohol  or  in  lysol.  Some  hospitals  use  doubtful  sub- 
stitutes for  lysol  because  they  are  cheap.  It  is  the  busi- 
ness of  the  pathologist  to  show  the  pupils  that  there  are 
certain  goods  which  can  stand  a  long  period  but  not  a 
high  degree  of  heat,  and  that  the  result  is  as  good  as  if  it 
were  a  shorter  time  and  a  higher  temperature.  We  are 
told  that  a  properly  tempered  steel  blade  is  finished  at 
500°  F.,  and  that  no  boiling  can  spoil  it;  but  not  many 
hospitals  buy  blades  as  fine  as  that,  and  theirs  are  spoiled 
by  boiling. 

The  basic  principles  in  bacteriology  are  quite  uniform 
throughout  the  world,  and  if  the  pathologists  were  pressed 
into  service  by  the  Medical  Boards  the  technic  for 
sterilization  could  be  decided  on  in  a  way  that  would  be 
almost  uniform  everywhere  for  each  class  of  goods.  It 
should  be  so  simple  that  the  average  mind  could  easily 
comprehend  it. 

Tracing  the  Aseptic  Chain. — Asepsis  for  the  operating 
room  should  present  the  picture  of  a  chain  in  the  pupil's 
mind,  each  link  being  clean  and  free  from  germs  to  such  a 
distance  that  it  would  be  impossible  for  them  to  "crawl" 
or  "fly"  across  or  "fall"  into  the  wound,  or  be  carried 
thither  by  a  swift  random  gesture  of  an  assistant. 

The  skin  is  disinfected  with  iodin  (2.5  per  cent.)  and 
alcohol  (95  per  cent.),  the  umbilicus  being  left  in  abdominal 
work  to  the  last,  and  the  sponge  stick  then  thrown  aside. 
Towels  then  bounding  this  area  are  now  thrown  aside 
also,  and  the  new  ones  are  unfolded  (Fig.  16)  at  the  level  of 
the  patient's  body  and  not  until  the  patient  is  reached 
(Fig.  17).  They  had  lain  on  a  sterile  table  freshly  set  up. 
They  did  not  touch  anything  unsterile  in  transit.  They 
came  out  of  a  package  opened  by  the  unscrubbed  nurse  in 
such  a  way  that  her  hand  did  not  touch  the  inside  of 
the  bundle.  She  pinched  the  corners  in  turn  exteriorly, 
pulling  them  back  like  a  snap-dragon. 

The  knife  making  the  incision  had  been  sterilized  and 
laid  on  the  sterile  table;  it  had  been  handed  to  the  sur- 


120 


OPERATING   ROOM 


geon's  hand  by  an  assistant  whose  gown  had  long  sleeves 
and  whose  gloves  were  pulled  on  by  the  inside  of  the 
wrists,  as  they  are  done  up  in  their  packages,  so  that  his 
bare  fingers  never  touched  the  outside. 


Fig.  16. — Opening  towel  properly  folded  (to  the  center  twice). 

The  basin  in  which  the  surgeon  occasionally  rinses  off 
his  bloody  gloves  was  steam-sterilized  and  lifted  out  by  a 
nurse,  either  with  forceps  or  holding  it  only  by  the  out- 
side, and  supporting  it  from  the  bottom  while  being  filled 
with  sterile  water  at  the  sterilizer  faucets.  These  basins 


ASEPSIS 


121 


lie  face  down  in  the  utensil  sterilizer  so  that  the  steam  will 
rise  into  them.  The  scrubbed  nurse  takes  out  what 
goes  on  the  sterile  tables,  and  the  unscrubbed  nurse  what 
goes  on  the  tripods. 

i  •  • 


Fig.  17. — Laying  a  sterile  towel  by  the  field  of  operation,  opened 
only  after  passing  the  surgeon. 

The  moment  an  incision  is  made  none  of  these  things 
are  any  longer  sterile,  yet  the  operation  proceeds  with 
asepsis.  Contact  with  the  patient's  blood  and  tissues  has 
contaminated  all  the  assistants,  but  they  do  not  bring  any 


122  OPERATING   ROOM 

other  germs  to  the  patient.  But  his  blood  may  contain 
typhoid,  syphilis,  or  tuberculosis,  and  if  injected  into 
another  living  being  might  cause  instant  death.  A  surgeon 
should  not  say,  "I  can't  write  it  now,  I'm  sterile,"  because 
he  is  not  sterile  any  longer  after  he  has  exposed  the  sub- 
cutaneous tissue.  He  would  not  cut  out  a  piece,  of  that 
tissue  and  rub  it  in  his  own  eyes.  A  part  from  that 
wound  might  infect  the  patient's  own  eyes.  Therefore, 
nothing  that  has  touched  that  patient,  or  that  has  during 
the  operation  been  handled  by  anyone  touching  that 
patient,  should  be  used  in  a  second  case  without  being 
sterilized  again. 

In  setting  up  for  a  case  the  nurse  should  open  as  many 
packages  as  she  is  going  to  need  before  she  scrubs,  to  help 
herself  as  much  as  she  can.  Many  times  in  a  private 
house  she  will  have  nobody  to  help  her.  All  hospital 
training  should  point  toward  competent  private  nursing, 
and  every  official  in  the  nursing  department  should  have 
a  couple  of  years  of  private  experience  in  .order  to  know 
what  to  prepare  pupils  to  meet.  Some  pupils  are  guilty 
of  scrubbing,  then  getting  into  their  gowns,  and  then  de- 
manding the  help  of  another  nurse.  "Every  tub  should 
stand  on  its  own  bottom"  is  a  homely  adage  that  applies 
well  here.  It  teaches  forethought,  which  is  most  essen- 
tial in  a  well-developed  character. 

Some  Errors  in  Technic. — It  has  already  been  said  that 
germs  travel  through  moist  goods;  therefore,  since  the 
table  covers  may  be  wet  by  drops  of  water  from  the  basins 
or  by  blood,  they  should  both  be  removed  and  the  glass 
table  top  redisinfected  with  carbolic  acid  (5  per  cent.)  to 
render  inert  any  bacteria  found  there  before  "setting  up" 
for  a  second  case. 

Some  old-fashioned  hospitals  "set  up"  with  two  table 
covers,  one  loosely  thrown  above  the  other,  and  these 
are  peeled  off  in  turn  as  the  cases  proceed.  Heaven  help 
the  last  case!  But  a  pathologic  expert  can  at  once  dis- 
prove the  need  of  this,  and  its  very  clumsiness  makes  it 
dangerous.  Others  wind  table  legs  with  towels  so  as  to 


ASEPSIS  123 

have  safe  access  to  a  lower  shelf.  Rather  convert  this 
time,  material,  and  energy  into  buying  another  table. 
Keep  all  work  and  materials  on  a  level  with  the  patient. 
Do  not  buy  tables  with  lower  shelves. 

It  is  a  grave  error  to  allow  any  or  all.  of  the  working 
force  to  have  access  to  a  table  of  sterile  supplies.  If 
there  is  a  large  number  of  pupils  in  the  school,  a  hospital 
may  afford  one,  as  clean  nurse,  to  stand  at  the  sterile 
table  (rigidly  aloof  from  all  workers  or  patients),  who  may 
drop  on  the  work  tables,  without  contact,  what  is  needed  for 
the  case  in  progress.  But  she  must  touch  nothing  only 
her  own  tableful  of  goods. 

Otherwise,  when  there  is  no  clean  nurse  there  is  an 
absolutely  clean  start  made  for  the  second  case.  Each 
patient  must  have  all  the  advantages  that  the  hospital 
can  afford.  We  call  a  case  "clean"  where  we  hope  for 
primary  union,  yet  in  his  blood  may  be  we  know  not  what 
—typhoid,  tuberculosis,  or  lues.  Therefore  there  must  be 
rigid  watchfulness  to  keep  all  separate. 

For,  suppose  at  the  beginning  of  a  long  morning's 
work  we  have  provided  a  table  of  sterile  goods  without 
a  clean  nurse  stationed  at  it,  observe  what  happens. 
The  scrubbed  nurse  is  not  clean  the  moment  after  the 
first  blood  is  drawn.  She  then  goes  to  the  table  and 
selects  some  sponges.  After  the  surgeon  has  finished 
the  vaginal  work,  he,  in  his  blood-spattered  gown,  leans 
over  the  table  to  get  a  second  pair  of  gloves  for  the  ab- 
dominal work.  The  scrubbed  nurse  returns  to  get  some 
abdominal  wipes,  passing  her  gloves  over  the  area  touched 
by  his  gown.  A  smudge  of  blue  chalk  on  his  gown  during 
the  vaginal  work  can  thus  be  easily  transmitted  to  her 
sponges  for  the  abdominal  work  or  to  a  second  case.  Of 
course,  pathogenic  organisms,  growing  and  virulent,  are 
more  easily  passed  along.  Surgeons  select  the  cleanest 
case  first,  but  we  never  know  what  incipient  diseases 
their  anatomy  contains.  There  are  only  two  alterna- 
tives— a  clean  nurse  at  the  supply  table  or  laying  out 
open  only  what  is  needed  for  each  case,  the  extras  to  be 


124  OPERATING   ROOM 

brought  by  the  unscrubbed  "floater."  In  a  gynecologic 
hospital  the  dangers  are  worse,  though  less  apparent,  in 
the  form  of  venereal  disease  and  cancer. 

Where  a  clean  nurse  can  be  afforded,  she  is  all  ready  to 
wait  on  the  surgeons  for  the  second  case,  and  can  take 
instruments  also  for  it,  if  so  it  is  decided,  so  that  the 
first  instrument  nurse  can  scrub  and  take  her  place  on  the 
supply  table,  then  being  ready  for  instruments  on  the 
third  case. 

All  the  apparatus  directly  concerned  with  the  pa- 
tient's inhalation  of  anesthetics  should  be  boiled  each 
time  it  is  used,  since  some  of  the  most  dangerous  germs 
of  lues  and  tuberculosis  are  transmitted  by  mouth,  as 
well  as  tonsillitis,  la  grippe,  and  others  more  speedily 
terminated  but  more  prostrating  and  annoying,  espe- 
cially through  the  dangers  from  coughing,  inducing  hernia, 
and  undoing  the  surgeon's  work. 

Some  persons  when  they  are  scrubbed  act  as  if  they 
were  sterile;  nay,  more,  as  if  they  were  themselves  germi- 
cidal,  that  if  a  germ  lit  on  them  they  would  blast  it  with 
instantaneous  death.  That  they  care  for  the  patient  well 
is  true,  but  it  is  sadly  equally  true  that  they  can  carry 
infection  from  that  patient  to  the  supplies  needed  for  an- 
other. There  are  two  kinds  of  caution  to  take  during 
the  progress  of  an  operation:  (1)  Do  not  come  in  contact 
with  anything  that  will  harm  the  present  patient;  (2)  do 
not  carry  anything  away  from  this  patient  to  another. 

How  to  Handle  Goods  from  a  Jar.— When  rubber 
tubing,  packing,  or  any  other  goods  are  needed  that  are 
kept  in  sterile  jars  nothing  that  was  used  on  the  case  should 
be  inserted  into  those  receptacles.  If  a  nurse  is  alone  in 
setting-up  and  assisting  the  surgeon  she  must  lay  out  all 
she  thinks  he  will  need  before  he  comes,  inserting  into  the 
jars  a  long  forceps  kept  in  lysol  or  alcohol,  as  the  case 
may  be  abdominal  or  eye,  and  not  be  stingy  about  it 
either,  for  it  is  much  easier  to  resterilize  packing  than 
to  make  a  large  lot  for  a  drainage  case  thus  caused.  It  is 
extravagant  to  resterilize  more  often  than  necessary,  both 


ASEPSIS 


125 


in  time,  gas  or  steam,  and  deterioration  of  materials 
(rubber,  rubber"  tissue,  etc.),  but  there  must  not  be  a 
central  meeting-place  for  the  clean  and  the  unclean  in 


Fig.  18. — Pouring  out  drugs,  holding  the  cork  in  an  aseptic  manner. 

' 'sterile"  supply  jars.  This  long  forceps,  kept  scrubbed 
with  Bon  Ami  every  day  and  dried  out  at  night  to  pre- 
vent rusting,  takes  the  place  of  a  clean  nurse.  Lysol 


126  OPERATING    ROOM 

(2  per  cent.)  is  strong  enough  to  render  them  germ  free, 
but  should  not  be  carried  into  an  eye  solution.  Rinsing 
in  sterile  water  is  necessary.  If  jar  lids  must  be  laid  down, 
the  sterile  side  is  left  uppermost  so  as  to  touch  no  unclean 
thing  (Fig.  18). 

A  dram  of  any  drug  to  a  pint  of  water  makes  a  1  per 
cent,  solution.  But  why  is  this?  To  know  why  means 
that  one  never  forgets  this  rule: 

1  per  cent,  means  TTO". 

In  1  pint  are  16  ounces,  or  128  drams. 

TTfr  of  a  pint  =  TTO  of  128  drams,  or  ly2A  drams. 

T2A,  about  |,  is  a  sufficiently  small  fraction  to  be  dis- 
regarded in  small  solutions,  the  pathologists  say.  In 
making  up  solutions,  the  amount  should  always  be  cal- 
culated on  paper  and  submitted  to  the  supervisor  for  her 
O.  K.  Women  ordinarily  have  very  little  mathematical 
ability,  and  if  the  nurse  can  be  made  to  feel  the  dangers 
of  a  mistake  and  a  doubtfulness  of  her  own  arithmetical 
powers,  much  will  be  avoided  that  is  shameful  and  un- 
pleasant. All  the  containers  in  the  operating  room  should 
be  measured  with  graduates — ounce,  pint,  or  gallon — 
often  enough  to  know  at  once  the  contents  of  any  ordinary 
vessel  by  the  eye,  and  then  in  working  a  graduate  should 
always  be  used. 

In  setting-up  for  operations,  too,  the  old  rule  must 
be  observed  thoughtfully,  not  with  one's  mind  on  the 
play  or  the  dance  of  the  night  before — "Read  the  label 
three  times."  What  was  the  nurse  thinking  about  who 
filled  the  bichlorid  arm-tank  for  an  obstetrician  with 
pure  carbolic  acid?  Nobody  can  estimate  the  loss  it 
caused  to  the  physician,  to  the  patient  in  labor,  to  the 
nurse  herself,  to  the  women  of  his  private  practice,  hoping 
for  the  advantages  of  his  own  personality,  so  strong  in 
obstetric  work,  when  it  came  their  turn.  The  institution 
loses  in  prestige,  all  by  one  moment's  lapse  on  the  part  of 
the  nurse,  who  could  not  have  done  it  if  she  had  been  early 
forced  into  a  groove  of  thoughtful  habit. 

To  put  a  bell  on  poison  bottles,  or  to  stick  a  long  pin 


ASEPSIS  127 

through  their  cork,  acts  as  a  good  warning  to  nurses  who 
do  not  keep  their  mind  on  their  work. 

Dusting. — Care  must  be  regularly  taken  with  the  high 
dusting  first  thing  in  the  morning,  so  that  no  foreign  body 
can  fall  into  the  wound  from  the  fixtures.  Owing  to  the 
laws  of  physics  governing  air,  heat,  dust,  etc.,  it  is  diffi- 
cult to  believe  that  any  area  over  an  operating-table  is 
clean,  but  the  nurse  must  prepare  the  overhead  space 
perfectly,  so  as  not  to  make  her  other  work  useless,  in- 
stead of  shunning  it  and  leaving  it  to  the  orderly. 

Orderlies. — Many  times  there  will  be  a  change  of 
orderly,  or  days  when  none  is  to  be  had.  The  new  ones 
must  be  thoroughly  taught  and  watched  afterward; 
this  last  without  their  being  aware  of  it.  It  is  not  going 
to  hurt  any  nurse  to  mount  a  solid  stepladder  or  table 
and  dust  the  chandeliers;  but  when  an  orderly  is  on  duty 
it  must  be  done  to  the  same  degree  of  perfection  to  the 
nurse's  certain  knowledge.  The  orderly  is  a  very  un- 
pleasant factor  at  times  in  the  working  of  a  hospital, 
since  it  is  a  dependent,  parasitic  existence  for  an  able- 
bodied  young  man  in  these  days  when  the  trades  com- 
mand such  good  pay  and  securities  in  the  form  of  work- 
men's compensation.  It  is  not  safe  to  assume  anything 
about  an  orderly's  intelligence  or  conscience,  and  the 
nurse  must  see  that  his  work  is  thorough.  Yet  there 
are  a  few  simple,  faithful  souls  who  take  a  humble  pride 
basking  in  the  effulgence  reflected  from  a  great  surgeon, 
working  with  zest  to  share  in  the  results  behind  the 
scenes  that  ensure  his  brilliant  successes. 

It  is  very  dangerous  to  the  purity  of  the  air  to  have 
vents  in  a  glass  dome  roof  or  curtains  sliding  on  a  sky- 
light to  darken  a  room  for  the  use  of  "scopes,"  or  a  ven- 
tilating fan  near  the  ceiling,  set  in  commotion  during  an 
operation.  The  scene  must  be  all  set  before  the  case 
comes  on  as  to  air,  light,  and  heat. 

The  anesthetist  has  been  sometimes  walled  off  from  a 
view  of  the  wound,  but  this  has  its  disadvantages.  The 
gain  in  asepsis  is  more  than  counterbalanced  by  his  loss 


128  OPERATING   ROOM 

of  control  when  he  cannot  see  how  far  his  patient's 
abdomen  is  relaxed.  Better  discipline  the  one  curious 
gazer  who  forgets  his  anesthetic  in  interest  in  the  wound 
than  deprive  ten  good  anesthetists  of  their  chief  gauge  of 
control.  The  anesthetic  may  be  as  fatal  in  its  termina- 
tion as  the  wound,  and  must  have  free  play. 

The  anesthetist  changes,  with  the  other  men,  into  a 
clean  white  suit  and  cap  to  save  his  own  from  odors  and 
vomitus,  as  well  as  to  exclude  from  the  operating  room 
all  germs  of  the  trolley  car  or  pavement — i.  e.,  scarlet 
fever,  tonsillitis,  la  grippe,  etc. 

Contaminated  Instruments. — During  an  operation  if 
any  instrument  becomes  contaminated  with  pus  it  should 
be  dropped,  not  on  the  floor,  but  into  a  floor  basin,  whence 
it  is  carefully  taken  to  be  washed  and  reboiled  by  the 
nurse.  Towels  that  become  thus  contaminated  are 
carefully  drawn  away  from  the  wound,  not  flopped  about, 
then  rolled  up,  disinfected,  and  washed  in  the  hopper,  so 
that  bacteria  have  no  time  to  spread.  It  is  very  foolish 
to  get  all  the  towels  and  instruments  smeared  with 
pus  in  a  dirty  case.  It  can  with  a  very  little  thoughtful 
care  be  mopped  up,  dammed  up,  and  disinfected.  This 
practically  renders  this  case  innocuous  to  all  following  it 
as  to  the  general  furnishings,  the  tables  and  tripods  and 
irrigating  stands  not  being  smeared. 

Breaks  in  Asepsis.— Everyone  in  the  working  staff 
should  be  on  the  "qui  vive"  for  "breaks"  in  aseptic 
technic.  Among  surgeons  the  word  "technic"  means  the 
method  of  incising,  ligating,  extirpating,  etc.,  in  classic 
operations — i.  e.,  the  direction  and  length  of  the  wound, 
the  materials  used,  and  the  instruments  required.  But 
in  nurses'  slang  the  word  "technic"  means  their  share  in 
the  operating  room  in  preserving  asepsis.  Instead  of 
saying  "break  in  technic"  the  phrase  "break  irr  asepsis" 
should  be  used.  It  is  unfortunate  that  this  confusion  of 
terms  has  arisen.  Let  each  one  try  to  head  it  off.  At  any 
rate,  all  language  should  be  clear,  forcible,  and  uniform. 
A  dressing  cover  is  not  a  "skin"  but  a  dressing  cover. 


ASEPSIS  129 

What  is  a  "probang"?  What  is  a  "whistle"?  Each 
article  should  be  named  by  its  shape,  material,  and  use. 
Yet  so  monotonous  is  routine  that  nurses  fasten  delight- 
edly on  the  new  language  of  the  operating  room  and  use 
it  to  the  point  of  boredom. 

The  operating-table  makes  a  lodgment  for  all  the  bac- 
terial content  of  drainage,  irrigations,  and  ordinary  con- 
tact with  dressings  and  towels.  It  requires  thorough 
washing  with  soap  and  water  and  carbolic  acid  (5  per 
cent.)  between  cases,  and  a  brisk  whitening  or  polishing 
with  Bon  Ami  each  evening. 

Floors  are  more  satisfactory  if  white  at  all  times. 
Between  cases  they  are  mopped,  first  with  cold  water  to 
remove  blood,  then  with  clean  water  and  soap,  then 
with  carbolic  acid  (1  :  40).  This  requires  three  different 
mops.  The  head  nurse  supervises  the  care  of  these 
mops  with  extreme  vigilance,  because  not  only  is  blood 
a  first-class  medium  for  germ  culture,  but  where  •  the 
operators  wear  street  shoes  instead  of  sneakers,  or  do  not 
wear  goloshes,  millions  of  tetanus  germs  are  carried  in. 
These  mops  require  washing  and  boiling,  then  sunning 
and  airing.  The  unscrubbed  nurse  should  be  proud  to 
wield  a  mop  during  the  progress  of  a  case — to  prevent 
sloppiness  and  head  off  infection,  to  show  that  she  has  an 
interest  in  the  case.  A  well-equipped  suite  has  a  hopper 
room  with  boilers  for  various  utensils  such  as  these.  The 
white,  small  round  peppermint  lozenge  tile  finds  most 
favor.  It  shows  its  cleanliness  and  is  easily  repaired. 

The  few  stands  and  cases  which  the  operating  room 
holds  must  be  thoroughly  cleaned  once  a  week,  and 
always  pulled  out  on  their  large,  strong,  noiseless  casters 
to  get  at  the  walls  behind.  The  instruments  are  boiled 
after  each  case  before  being  laid  on  the  shelves. 

The  walls  collect  dust,  and  require  brushing  every  week 
and  washing  every  three  months.  To  disinfect  the  whole 
room  by  modern  equipment  there  is  a  simple  device  con- 
trolled by  the  engineer  from  outside,  by  which,  when  the 
room  has  been  sealed  externally,  live  steam  is  turned  on 

9 


130  OPERATING   ROOM 

and  fills  every  corner,  destroying  every  germ  and  spore 
better  than  any  other  known  agent  can  do.  Some 
hospitals  permit  the  ghastly  mistake  of  simply  washing 
and  drying  instruments  without  boiling  them  before 
laying  them  away.  This  conveys  many  bacteria  to  the 
case  shelves,  where  in  the  very  humid  atmosphere  they 
multiply  to  the  millions.  One  could  reasonably  expect 
primary  union  in  an  emergency  operation  if  the  instru- 
ments had  been  boiled  when  put  away  on  shelves  pol- 
ished with  alcohol  a  day  or  so  before.  There  is  no  excuse 
for  these  errors  if  nurses  would  but  use  their  brains  and 
apply  what  they  hear  (but  do  not  heed)  in  their  lectures 
on  bacteriology. 

Shoes. — Some  surgeons  do,  and  all  should,  wear  special 
shoes  for  operating-room  work  of  a  style  and  shape  that 
will  not  induce  fatigue.  As  nurses  do  not  wear  their 
hospital  shoes  on  the  street,  they  do  not  require  special 
footgear  for  the  operating  room.  But  every  nurse 
should  keep  on  hand  two  pairs  in  good  condition,  however, 
so  as  to  change  in  her  time  off  for  the  purpose  of  reliev- 
ing the  feet  of  perspiration  or  heat  and  of  airing  the  shoes 
in  a  sunny  window.  To  secure  efficiency  in  her  staff  a 
careful  head  nurse  will  watch  and  assume  her  authority 
in  these  points. 

Health  of  Attendants. — It  is  imperative  that  each 
person  taking  part  in  the  care  of  the  operating  room 
should  be  in  perfect  health.  In  one  instance  the  men 
employees  lived  in  the  basement  of  the  nurses'  home, 
where  the  strong  odor  of  burning  calomel  was  observed 
for  a  whole  evening,  coming  up  from  the  room  of  the 
operating  room  orderly  through  the  hot-air  radiators 
which  communicated  with  the  nurses'  rooms.  He  was 
treating  himself  for  an  attack  of  lues  on  a  prescription 
from  one  of  the  interns  in  the  hospital  dispensary  who  had 
not  deemed  it  necessary  to  report  the  affair  "for  fear  the 
man  would  lose  his  job."  Such  orderlies  should  be  given, 
on  the  slightest  suspicion,  a  complete  physical,  not  verbal, 
examination.  Such  interns  should  be  suspended. 


ASEPSIS  131 

Emergency  Cases. — If  cases  are  brought  off  the  street 
for  immediate  surgical  relief,  in  those  institutions  which 
now  so  admirably  meet  the  instant  needs  of  their  con- 
stituency, these  sufferers  can  be  cloaked  by  large  gowns 
over  all  until  after  the  operation.  But  there  must  be 
sincere  and  sympathetic  co-operation  between  the  office 
where  operations  are  booked  by  the  surgeons  and  the 
operating  room.  A  case  should  not  be  rushed  to  the  oper- 
ating room  as  an  emergency  if  it  is  not  an  emergency. 
But  the  operating  room  should  always  be  instantly  and 
cheerfully  prepared  and  the  work  done,  and  if  deceived 
a  protest  calmly  entered  afterward.  There  is  no  doubt 
that  a  woman  capable  of  conducting  an  operating  room 
has  a  sound,  sane  mind,  and  should  have  a  reliable  court 
of  appeal  to  take  her  troubles  to.  If  she  does  her  work 
well,  she  is  of  more  value  to  the  hospital  than  any  surgeon 
is  who  stoops  to  deceit.  Careless  diagnosis  is  just  as 
culpable  as  deceit.  The  office  or,  in  other  words,  the 
business  superintendent  must  not  expose  all  his  patients 
to  the  dangers  from  overhaste  with  the  one.  He  may  be 
quite  too  anxious  to  cater  to  the  whims  of  one  attending 
or  director,  and  overlook  the  axiom  of  "doing  the  greatest 
good  to  the  greatest  possible  number/'  forcing  irregulari- 
ties on  the  operating  room  that  may  prove  it  a  menace 
instead  of  a  means  for  relief. 

Contagious  Cases. — Sometimes  it  is  humane  and  im- 
perative to  admit  a  case  of  scarlet  fever  requiring  an  im- 
mediate mastoid  operation  from  a  home  too  poor  to  make 
the  work  possible.  In  such  a  case  the  city  should  provide 
special  nurses  if  there  are  not  enough  pupils.  An  isolated 
room  can  be  quickly  fitted  up  as  an  operating  room  in  a 
sanitary  manner  and  the  patient  put  to  bed  there  after  it 
is  finished.  Many  towns  are  not  well  equipped  for  the 
care  of  contagion,  and  the  .philanthropists  expect  the 
hospital  to  meet  all  these  exigencies.  But  the  oldest 
nurse  will  emphatically  state  that  when  a  humane  act 
is  performed  in  the  midst  of  contagion  harm  seldom  comes 
of  it.  But  such  conditions  should  be  a  potent  argument 


132  OPERATING   ROOM 

for  building  an  isolation  hospital.  There  should  be  a 
small,  flexible  committee  to  govern  operating-room 
affairs,  consisting  of  the  less  and  the  greater  surgeons,  the 
superintendent,  the  directress  of  nurses,  and  the  operat- 
ing-room supervisor.  The  directress  of  nurses  is  respon- 
sible for  the  health  of  her  nurses  and  their  work.  If 
there  is  any  "crooked  work"  in  the  operating  room  she 
cannot  be  compelled  to  provide  nurses  for  that  service, 
since  the  state  does  not  specify  this  nor  interrogate  candi- 
dates for  the  degree  of  registered  nurse  on  the  problems 
of  that  service.  She  also  can,  through  the  operating-room 
supervisor,  control  any  foreign  nurses  thrust  in  by  a 
hostile  superintendent.  If,  then,  any  steps  have  been 
taken  through  greed  rather  than  altruism  and  humane 
feeling  to  put  undue  burdens  on  the  operating  room, 
rendering  it  unclean  and  slow  in  service  for  later  cases, 
this  committee  can,  by  talking  the  matter  over,  adjust  it 
and  prevent  a  recurrence. 

It  is  not  proper  to  ask  an  operating  room  to  sterilize 
supplies  made  in  a  home  where  contagion  exists,  nor  the 
blankets,  etc.,  used  on  a  contagious  case.  Other  means 
must  be  employed.  This  is  a  duty  of  the  Board  of  Health. 
Every  modern  town  should  have  public  means  of  disin- 
fecting anything.  There  is  no  emergency  connected 
with  the  disinfecting  of  a  mattress.  Public  aggrega- 
tions of  infection  must  not  be  brought  to  the  hospital 
where  people  come  trustingly  to  be  operated  on  while 
weak  and  ill. 

"Clean"  Cases. — An  emergency  off  the  street  is  "clean" 
in  the  true  sense  of  the  word.  A  grimy  coal-heaver  with 
a  broken  leg  is  a  clean  case,  where  a  dainty  child  with  a 
ruptured  appendix  is  a  dirty  case.  The  coal-heaver  may 
have  been  inoculated  with  the  tetanus  germ  off  the  ground, 
but  the  moment  he  comes  in  he  is  given  a  dose  of  tetanus 
antitoxin.  But  he  must  get  absolutely  sterile  dressings, 
catgut  never  opened  before,  and  newly  sterilized  towels, 
with  gowns,  caps,  and  all  the  "pomp  and  circumstance  of 
war"  against  bacteria.  Well  cloaked,  he  is  no  menace  to 


ASEPSIS  133 

the  interior.  But  a  woman  with  puerperal  sepsis  is  a 
menace  to  everybody,  and  should  not  be  treated  in  an 
operating  room  where  eye  work,  bone-plating,  and 
hernias  are  done,  since  her  infection  is  powerful,  in- 
sidious, and  dangerous. 

It  is  wise  to  have  a  small  room  with  complete  but 
modest  equipment  in  which  to  segregate  what  are  known 
to  be  septic  cases,  and  to  disinfect  it  with  live  steam  when- 
ever it  is  used. 

Nurses  Who  are  111. — Nurses  with  tonsillitis,  la  grippe, 
infected  fingers,  et  al.,  must  be  kept  out  of  the  operating 
room.  Neither  are  the  wards  a  safe  place  for  them,  since 
they  are  now,  when  ill,  more  susceptible  to  the  infections 
of  the  patients.  Where  can  they  go?  Off  duty.  Feed 
them  properly  and  keep  them  well.  House  them  com- 
fortably, then  watch  their  conduct.  Inculcate  the  idea 
of  dressing  warmly  around  the  neck  and  limbs  so  as  to 
reach  a  healthy,  graceful  prime,  and  levy  a  heavy  penalty 
for  time  lost  by  ill-health.  The  operating  room  owes  the 
patient  a  duty  and  must  not  load  him  with  additional 
disease. 

Catgut  is  a  fertile  source  of  trouble,  since  it  is  an  animal 
product.  The  equipment  for  making  catgut  is  very  ex- 
pensive and  the  responsibility  is  very  great.  No  amount 
of  money  can  buy  nurses  in  these  days  of  women's  rights, 
and  equipment  is  always  cheaper  than  human  blood  or 
brains.  Buy  the  catgut  from  a  reliable  firm,  and  do  not 
heap  on  the  nurses  a  burden  that  has  no  connection  at  all 
with  their  work  as  private  specials  in  the  homes.  The 
men  who  make  catgut  for  the  firms  who  deal  in  it  have  no 
other  responsibility.  They  have  no  life-saving  work  to 
do;  their  hours  are  regular  and  they  are  trained  for  only 
one  thing.  But  if  catgut  is  made  in  a  hospital,  and  a 
surgeon  with  a  boil  on  his  finger  gets  an  infection  in  the 
hernia  he  has  operated  on,  the  vials  of  his  wrath  are  un- 
justly let  loose  on  the  nurses.  Some  firms  sell  good 
catgut.  Buy  only  from  them.  Do  not  change  for  lower 
prices.  The  supervisor  must  follow  the  cases  and  see 


134  OPERATING   ROOM 

what  is  the  effect  with  different  kinds  of  catgut.  It  is  a 
well-known  fact  that  some  penny-wise,  pound-foolish 
hospitals  have  changed  over  to  cheaper  catgut,  and  have 
had  a  run  of  insidious,  annoying,  pride-reducing  infections 
in  what  should  have  been  primary  union,  not  deeper, 
and,  therefore,  surely  due  to  the  catgut.  This  is  rank 
robbery  of  the  patient's  time  and  money  through  length- 
ening his  stay.  The  operators  have  an  uneasy  feeling  as 
well  as  their  colleagues  outside  who  send  the  cases  in. 

Gloves  and  towels  with  holes  are  not  only  no  good,  but 
harmful.  All  holes  must  be  mended.  Tapes  and  buttons 
are  sewed  on  gowns  in  order  to  fasten  perfectly,  since 
sloppy  gowns  trail  over  everything.  If  a  surgeon  finds 
that  he  has  slit  or  pierced  his  glove  during  a  case  he  must 
change  it  at  once;  otherwise  it  lets  out  into  the  wound 
all  the  poisons  excreted  in  his  perspiration  and  collecting 
there  for  one-half  hour  in  a  warm  moist  bed  for  bacteria. 
Perspiration  itself  acts  as  a  foreign  poisonous  body  also. 
Each  nurse  should  become  an  expert  in  mending  gloves 
smoothly  and  solidly.  A  package  of  sterile  powder  is 
done  up  inside  of  each  glove  case.  They  are  opened  by  the 
dirty  nurse  in  such  a  way  that  she  does  not  touch  the  part 
whence  the  surgeon  withdraws  the  glove  (see  Fig.  1). 
They  may  also  be  opened  while  "setting-up"  and  laid  on 
the  table  beside  the  instruments,  from  which  the  surgeon 
must  not  take  them  with  his  bare  fingers.  The  instrument 
nurse  hands  them  to  him.  Dry  sterilization  is  much 
more  speedy  and  comfortable  for  the  surgeon,  but  it  runs 
the  bills  up  because  it  ruins  rubber.  Boiling  the  gloves, 
or  "wet  technic,"  is  much  cheaper  and,  like  many  other 
things,  more  uncomfortable.  The  surgeon  first  takes 
the  powder  out,  dusts  it  over  his  fingers,  then  pulls  on  the 
dry  gloves  by  their  inside  surface,  the  wrists  being  folded 
back. 

A  strict  technic  must  be  observed  with  bottles,  jars, 
and  shakers,  which  can  only  be  perfected  by  constant 
criticism  and  practice.  A  solution  of  cocain  or  adrenalin 
must  not  be  heated,  but  it  can  be  kept  sufficiently  clean 


ASEPSIS  135 

to  be  harmless  with  a  little  care.  The  cork  can  be  held 
in  the  little  finger  of  the  left  hand  while  pouring.  The 
top  side  of  a  shaker  should  not  be  laid  down.  A  jar  lid 
is  laid  down  upside  down.  When  preparing  to  shake 
aristol  over  a  raw  wound  wet  a  towel  in  bichlorid,  and, 
winding  it  around  bottle  and  wrist  so  as  to  cover  any  dust 
on  their  surfaces,  shake  gently  over  the  bleeding  area. 

Sterile  goods  must  not  be  carried  under  the  armpit 
on  account  of  perspiration,  any  more  than  we  want  a 
maid  to  run  with  bread  from  the  baker's  under  her  arm. 

Tap-water  is  quite  clean  enough  for  the  bichlorid 
tank,  since  the  drug  kills  all  the  bacteria  in  the  water 
easily.  It  takes  a  big  load  off  the  water  sterilizers  to  know 
this.  Furthermore,  economy  can  be  exercised  in  using 
70  per  cent,  alcohol,  which  is  just  as  effective  as  95  per 
cent.,  and  less  costly  by  about  one-fourth  the  price. 

Every  year  marks  an  added  simplicity  in  operating 
technic;  for  instance,  comparing  the  slops  of  ten  years 
ago — big  wet  abdominal  dressings,  irrigations,  and 
douches — with  the  present  dry  method — no  irrigation, 
no  cleansing  with  green  soap,  merely  painting  a  little 
iodin  over  the  crusts  around  a  cut.  The  results  continue 
to  improve,  and  each  worker  in  this  field  should  observe 
much,  compare  all,  and  contribute  any  original  idea  she 
has  for  the  common  good. 


CHAPTER  X 

FORMULAE   AND   DIRECTIONS 

Thiersch's  Solution.— A  valuable  antiseptic  for  nose 
and  throat: 

Salicylic  acid 2  parts. 

Boracic  acid  crystals 12  parts. 

Water 1000  parts. 

Carrel-Dakin  Antiseptic. — Dissolve  140  gm.  of  an- 
hydrous sodium  carbonate  in  10  liters  of  water.  Add 
200  gm.  of  chlorinated  lime.  Shake  the  mixture  thor- 
oughly, and  after  one-half  hour  siphon  off  the  super- 
natant fluid  from  the  precipitate  of  calcium  carbonate. 
Filter  this  fluid  through  cotton.  Make  the  clear  fluid 
neutral  or  acid  by  adding  boric  acid,  drop  by  drop,  until 
a  drop  of  the  solution  does  not  redden  a  few  drops  of 
phenolphthalein  solution.  Usually  this  requires  25  to 
40  gm.  boric  acid.1 

lodoform  Packing  (I). — 

lodoform  powder 15  c.c. 

Normal  saline 120  c.c. 

Carbolic  acid  solution  (5  per  cent.) 5j- 

Tincture  green  soap 5ss. 

Glycerin 5  ss- 

Sterilize  in  open  jars  for  twenty  minutes  at  15  pounds;  lids  be- 
side jars  in  the  dressing  sterilizer. 

In  making  iodoform  gauze  the  cloth  will  have  been 
previously    drawn,    ravelled,    or    folded    in    odd    half- 
hours  in  the  anesthetic  room,  or  by  special  nurses  with 
leisure  and  willingness  to  help.     Bandages  are  ravelled 
at  the  ends  to  leave  smooth,  threadless  borders,  because 
1  American  Journal  of  Medicine,  September,  1915.     • 
136 


FORMULAE    AND    DIRECTIONS  137 

threads  in  a  granulating  wound  or  a  curetted  uterus  delay 
healing,  acting  as  a  foreign  body.  The  fuzz  is  snipped  off 
so  that  the  remaining  part  will  exactly  measure,  when 
spread  out  single,  J,  1  inch,  or  2  inches,  as  labelled.  The 
plain  gauze  is  then  sterilized  once  in  muslin  covers  or  in 
open  jars  in  12-inch  to  5-yard  strips  for  ears,  uteri,  etc. 

The  drugs  of  the  formula  are  mixed  with  a  sterile 
spatula  in  a  sterile  glass  graduate,  using  a  sterile  minim 
glass  to  measure  small  amounts,  then  poured  into  a  flat 
glass  basin,  also  boiled.  The  powder  is  thoroughly  emul- 
sified in  the  green  soap  and  glycerin  before  adding  the 
watery  solutions.  No  stain  is  left  on  glass. 

The  glass  table  is  then  "set  up"  with  an  opened  pack- 
age of  towels,  of  packing,  sterile  brown  glass  jars,  and 
the  mixture.  The  nurse  scrubs,  lays  a  towel  on  the  table, 
brings  her  materials  upon  it,  and  begins  folding  the  gauze 
in  plaits  until  it  absorbs  the  mixture  in  all  parts.  Then 
she  squeezes  out  all  she  can  and  lays  the  pieces  in  the 
jars. 

lodoform  Packing  (II). — 

lodoform  powder 5y. 

Glycerin §j. 

Bichlorid  of  mercury  solution  (1  :  1000) §v. 

Sterilize  in  test-tubes  with  a  cotton  plug  and  a  muslin  cover  for 
twenty  minutes  at  15  pounds  in  the  dressing  sterilizer. 

Preparation  of  Catgut.1— Plain  catgut  is  used  in  tissues 
which  absorb  very  rapidly  and  where  the  strength  of  the 
union  will  not  have  any  strain. 

To  iodize  catgut  increases  its  tensile  strength.  Chromic- 
ized  catgut  is  hardened  to  a  still  greater  degree  than  the 
plain  and  absorbs  more  slowly,  therefore  the  line  of 
union  is  much,  stronger  because  the  patient's  tissues  do 
their  own  uniting.  Chromic  gut  is  due  to  be  absorbed  in 
the  time  mentioned  on  the  label,  as  ten,  twenty,  or  forty 
days.  The  union  of  tissue  sutured  with  ten-day  is  usually 
satisfactory,  the  others  being  used  for  ligatures.  In  a 

1  See  Dr.  Brickner's  comprehensive  work,  "The  Surgical  Assist- 
ant." 


138  OPEKATING   BOOM 

perineum  after  laceration  by  childbirth  great  strain  is 
felt  at  each  stool,  therefore  chromic  gut  is  used. 

Kangaroo  tendon  is  always  chromicized  and  is  very 
strong.  It  is  used  to  suture  bone — e.  g.,  a  fractured 
patella — in  place  of  the  old  silver  wire;  also  aponeuroses 
or  ligaments,  as  in  inguinal  and  femoral  hernia.  These 
various  kinds  of  gut  are  bought  in  chloroform  in  tubes, 
boiled  before  using. 

Horsehair  acts  like  silkworm-gut.  It  is  boiled  before 
using  and  keeps  in  alcohol.  Horsehair  sutures  are  to  be 
removed. 

Silkworm-gut  may  be  boiled  as  used  and  carried  dry 
in  a  physician's  kit,  or  boiled  and  kept  in  alcohol  in  an 
operating  room.  It  is  used  in  sca4p  wounds,  in  a  mastoid, 
and  in  perineorrhaphy .  It  is  of  two  colors,  white  and 
black,  white  showing  up  well  in  negroes,  and  vice  versa. 
The  black  should  be  iron-dyed  to  secure  a  fast  color. 

Surgeons'  silk  should  be  threaded  in  15-inch  lengths 
in  all  grades  of  strength  on  all  needles  suitable  for  wounds 
requiring  silk,  and  then  run  through  a  hemmed  square 
of  white  flannel,  afterward  dry  sterilized,  but  not  too 
often,  since  the  dry  method  rots  the  silk  more  than 
boiling.  But  this  saves  the  trouble  of  threading  during 
an  operation. 

Bone-wax  is  boiled  for  ten  minutes,  then  poured  into 
a  second  sterile  dish,  cooled,  covered,  and  wrapped  in  a 
sterile  towel  to  be  carried  about.  It  is  so  rarely  used  in 
a  general  operating  room  that  the  surgeon  needing  it 
should  bring  it. 

Aluminum  Acetate  Solution. — 

Plumbi  acetate 3.5 

Alumen 9.0 

Aqua ad  100.0 

Mix  and  filter. 

Dilute  when  using  with  five  to  eight  times  as  much 
water.  Never  use  it  full  strength.  It  macerates  the  skin 
and  its  ingredients  are  costly.  Gauze  is  moistened,  then 


FORMULAE    AND    DIRECTIONS  139 

laid  loosely  on  the  part,  then  the  limb  is  laid  on  a  rubber 
sheet  and  covered  with  a  high  cradle  to  let  air  circulate 
and  evaporation  take  place,  which  causes  reduction  of 
temperature.     Do  not  wrap  up  in  rubber. 
Boric  Acid  Solution. — 

Boric  acid  (crystals  preferably) 4  parts. 

Water 100  parts. 

Boil  until  clear.     To  use,  add  an  equal  amount  of  sterile  water. 

Pharmacists  employ  the  cold  process  by  adding  the 
powder  to  cold  water  and  letting  it  stand  and  absorb  until 
a  sediment  remains  (supersaturated). 

Normal  Saline. — Salt  exists  in  the  blood  in  the  pro- 
portion of  9  parts  to  1000,  or  A  per  cent.  It  is  not  neces- 
sary to  say  TG  of  1  per  cent. — it  is  a  reflection  on  the  in- 
telligence of  the  listener. 

Normal  saline  is  a  solution  which  contains  as  much  salt 
as  blood  does,  and  it  is  used  to  take  the  place  of  blood 
after  hemorrhage  or  to  stimulate  after  shock  until,  by 
taking  food,  the  patient  can  manufacture  new  blood. 
In  1  quart  are  32  ounces,  or  256  drams,  or  15,360  grains; 
T97F  per  cent,  of  1  quart  =  -&•  of  TW  of  15,360  grains  = 
138  grains.  t  In  1  quart  of  blood  are  138  grains  of  salt, 
therefore  to  make  1  quart  of  normal  saline  we  add  138 
grains  of  salt  to  1  quart  of  water  and  boil  it  for  five 
minutes  to  dissolve  thoroughly.  Filter  now  when  cooled 
through  sterile  cotton  and  sterile  filter-paper,  regularly 
plaited  to  fit  into  a  funnel  that  has  been  boiled,  into  a  set 
of  Florentine  flasks  of  1-pint,  1-quart,  and  2-quart  sizes. 
These  have  been  cleansed  with  a  bottle  brush  and  tinc- 
ture of  green  soap,  sterile  water,  alcohol,  and  a  final  rins- 
ing of  sterile  water,  and  stoppered  with  cotton  plugs  until 
ready  for  use.  Or,  dissolve  the  salt  in  the  proper  amount 
of  distilled  water,  which  if  kept  under  aseptic  conditions 
will  minimize  bacterial  activity  in  the  solution.  Any 
and  every  hospital  should  have  at  least  a  simple  distilla- 
tion apparatus  for  use  both  in  the  pharmacy  and  the 
operating  room. 


140  OPERATING   ROOM 

In  transferring  saline  solution  to  the  flasks  the  nurse 
should  "set  up"  a  sterile  table  with  sterilized  cotton, 
gauze,  tapes  and  utensils,  and  cleanse  her  hands  as  for 
operating.  When  the  flasks  are  filled,  only  in  the  round 
part  of  the  body,  they  are  set  on  the  floor  of  the  dressing 
sterilizer  and  sterilized  for  one-half  hour  at  15  pounds  for 
three  days  in  succession,  care  being  taken  to  mark  them 
as  being  done  once,  twice,  or  thrice.  If  at  any  time  crys- 
tals or  cloudy  spots  are  visible  the  solution  should  not 
be  used.  The  brilliant  clarity  of  well-made  saline  is 
always  very  noticeable. 

Bichlorid  of  Mercury  Solutions. — 1  pint  =  7680 
grains.  Pathologists  have,  found  that  many  of  these 
powerful  drugs  have  germicidal  power  at  the  strength  of 
1  part  of  the  pure  drug  to  1000  parts  of  water. 

TWO  of  1  pint  =  rioW  of  7680  grains  =  7M  grains, 
nearly  7J  grains;  therefore  any  drug  dissolved  in  water  in 
the  proportion  of  7J  grains  to  1  pint  makes  a  1  :  1000 
solution. 

1  :  2000  is  much  weaker.  One  man  against  two  thou- 
sand foes  stands  a  worse  chance  than  one  man  against 
one  thousand,  twice  as  bad  =  half  as  favorable.  To 
make  a  1  :  2000  solution  we  therefore  add  2  pints  of 
water  to  7|  grains  of  the  drug.  Or,  use  one-half  of  the 
amount  of  drug  to  the  pint  of  water.  One-half  of  7J  = 
J  of  -/  =  V"  =  3J  grains  to  1  pint  of  water.  But  nurses 
must  never  break  tablets  to  get  smaller  dosage.  Dissolve 
7J  grains  in  as  small  an  amount  of  water  as  possible  and 
take  one-half  of  it,  then  add  1  pint  of  water  to  make 
1  :  2000  solution. 

1  :  500  solution  means  more  drug  to  1  pint  or  less 
water  to  7J  grains,  in  the  proportions  of  twice  the  amount 
of  drug  or  one-half  the  amount  of  water,  i.  e.,  15  grains  to 
1  pint,  or  7J  grains  to  J  pint. 

Where  bichlorid  of  mercury  is  frequently  used  in  weak 
solutions  it  is  economic  to  keep  a  bottle  of  1  :  1000  solu- 
tion on  hand,  made  up  daily,  for  it  deteriorates.  We 


FORMULAE    AND    DIRECTIONS  141 

then  compute  thus:  For  a  vaginal  irrigation  we  need 
4  quarts  of  1  :  6000  solution  of  bichlorid  of  mercury. 

A  solution  1  :  6000  is  five  times  weaker  than  ( =  six  times 
as  weak  as)  a  1  :  1000  solution.  One-sixth  of  the  total 
amount  is  1  :  1000  solution,  the  rest  water.  Our  total  is 
4  quarts  (4  X  32  =  128  ounces);  J  of  128  ounces  =  2l\ 
ounces.  Take  21  ounces  of  1  :  1000  solution  and  add  to 
it  3  quarts  1 1  ounces  of  water  for  a  total  of  1  gallon. 

It  is  very  unsafe  to  keep  strong  solutions  of  mercury 
about.  There  may  be  undue  haste  in  measuring  them. 
Too  strong  bichlorid  solutions  act  as  an  escharotic  and 
corrode  the  flesh  instantly. 

Formaldehyd  is  a  gas  that  is  soluble  in  water  in  the 
proportion  of  formaldehyd  40  parts  to  water  100  parts. 
This  solution  is  called  formalin.  Other  fluids  are  sold, 
such  as  formacal,  having  the  same  ingredients,  but  not 
daring  to  use  the  original  trade  name,  which  has  certain 
commercial  rights  and  limitations.  Specimens  for  the 
laboratory  are  almost  universally  kept  in  formalin.  It 
does  not  shrink  the  delicate  tissues  of  an  eye.  Alcohol 
does.  Yet  it  preserves  and  hardens  for  section-cutting 
satisfactorily.  Specimens  must  be  placed  in  wide- 
mouthed  bottles  with  good  corks  to  prevent  evapora- 
tion and  concentration  of  the  drug  and  consequent  de- 
struction of  the  tissue. 

Formalin  is  40  per  cent,  formaldehyd;  4  per  cent, 
formalin  for  specimens  means  4  parts  out  of  the  bottle 
labelled  formalin  and  96  parts  of  water.  It  does  not 
matter  how  much  formaldehyd  is  in  this,  but,  to  be 
definite,  a  4  per  cent,  solution  of  formalin  contains  T$TF 
of  T4A  of  the  amount  of  formaldehyd  =  TWO-,  or  16  parts 
formaldehyd  gas  to  1000  parts  of  water.  Use  it  spar- 
ingly. It  is  expensive  and  hard  on  the  eyes  and  skin. 

Nitrate  of  silver  is  best  handled  in  tablets.  They 
deliquesce  when  exposed  to  air  and  deteriorate  if  ex- 
posed to  light,  therefore  must  be  kept  in  a  dark  blue 
or  brown  bottle  tightly  stoppered  with  glass  and  cot- 
ton. As  the  labels  must  contain  a  large  amount  of 


142  OPERATING   ROOM 

necessary  information,  the  print  is  consequently  very 
fine  and  mistakes  can  easily  occur.  In  one  instance  a 
nurse  interpreted  grs.  5  to  mean  gr.  .5,  or  gr.  J.  She  was 
distinctly  wrong,  because  the  s  indicated  more  than 
1  grain.  But,  being  in  doubt,  she  asked  an  intern  who 
came  from  one  of  "those  states  where,  though  there  is  not 
woman  suffrage,  the  gentlemen  always  agree  with  the 
ladies,  and  he  said  grs.  5  meant  gr.  f.  Therefore  she 
made  up  a  solution  for  bladder  irrigation  ten  times  as 
strong  as  it  should  have  been,  causing  the  patient  great 
pain.  Had  it  been  a  primary  lesion  he  would  have  died, 
but  being  an  old  man  with  a  very  old  infection  he  escaped. 
This  saved  her  shoulders,  but  not  her  conscience. 

Local  Anesthetics. — Argyrol,  cocain,  novocain,  and  all 
similar  drugs  for  eye  and  ear  work  or  local  anesthesia 
are  prepared  in  most  attractive  and  useful  form  by  cer- 
tain firms  so  as  to  be  handled  quickly  and  accurately, 
though  nothing  can  be  made  fool-proof.  The  varied 
opinions  about  how  long  certain  solutions  are  good  render 
the  tablet  method  the  safest. 

Cocain  comes  under  the  Harrison  law  in  New  York 
State,  and  the  operating  room  must  keep  an  accurate 
account  of  all  it  uses,  just  the  same  as  any  ward  or  any 
private  physician. 

These  drugs  must  not  be  heated.  Heat  destroys  cer- 
tain properties  or  develops  new  ones,  making  them  harm- 
ful to  the  patient.  They  are  so  carefully  handled  in  the 
wholesale  laboratories  which  are  strictly  conformed  to 
the  laws  of  hygiene  that  they  need  no  sterilization. 

One  Per  Cent.  Solutions. — It  is  said  that  4f  grains  to 
the  ounce,  to  be  accurate,  or  5  grains  to  the  ounce,  roughly 
speaking,  makes  a  1  per  cent,  solution.  Why  is  this? 
The  nurses  must  know  their  tables  of  dry  and  liquid 
measure  and  work  out  on  paper  all  percentage  problems,, 
to  be  shown  to  a  supervisor.  Arithmetic  in  its  eighth 
grade  forms  should  be  made  a  rigid  test  for  all  nurses  be- 
fore admitting  them  to  training.  1  ounce  =  8  drams; 
1  dram  =  60  grains;  1  ounce  =  8  X  60  grains  =  480 


FORMULAE    AND    DIRECTIONS  143 

grains.  Roughly  calculated,  we  call  1  ounce  500  grains. 
1  per  cent,  means  1  per  hundred,  or  T^-  iw  of  480 
grains  =  4-f  grains. 

Certain  eye  solutions  are  effective  in  the  strength  of 
1  per  cent.,  and  from  tablets  marked  so  many  grains  we 
should  make  up  the  solution  with  distilled  water  in  a 
sterile  basin. 

In  making  up  solutions,  find  out  how  much  is  going  to 
be  used.  Much  extravagance  is  shown  with  drugs  by 
making  too  large  an  amount  of  solution.  This  must  be 
checked,  so  that  nurses  may  not  waste  money  in  private 
families  by  foolishly  ordering  too  much  of  any  drug. 
Nurses  should  not  dispense.  It  shakes  the  confidence  of 
physicians  and  patients  to  see  nurses  with  doubtful 
arithmetical  ability  working  in  the  drug  room. 

The  difference  of  i  grain  (5— 4f)  makes  a  tremendous 
difference  in  the  effect  of  some  drugs,  especially  when  a 
fairly  large  solution  or  a  frequent  use  is  desired.  Pharma- 
cists must  never  use  the  extra  fifth.  Their  weights  and 
measures  are  always  uniform,  and  accurate. 

Rubber  Tissue  (Gutta-percha  Tissue). — To  cleanse  and 
sterilize  lay  on  a  cold  glass  table,  scrub  with  small  brush, 
using  tincture  of  green  soap  and  cold  water  on  each  side, 
rinse  under  cold  water  tap,  soak  over  night  in  bichlorid  of 
mercury  1  :  500.  Next  day  lift  with  sterile  forceps  into 
a  sterile  basin  of  water,  then  fold  in  dry  sterile  towels 
until  dry,  afterward  sterilize  in  the  dressing  sterilizer  for 
twenty  minutes  at  15  pounds'  pressure,  laying  gauze 
strips  between  every  two  layers  of  tissue.  Use  a  double 
muslin  dressing  cover.  This  is  used  mostly  for  cigarette 
drains.  It  does  not  stand  frequent  sterilization.  The 
supply  must  not  be  allowed  to  get  friable,  since  it  is  called 
for  at  critical  junctures.  A  successful  nurse  is  she  who 
frequently  goes  over  her  whole  stock  of  goods  to  see  its 
condition.  The  date  of  sterilization  for  each  gives  an  in- 
dication of  its  state.  Rubber  tissue  should  be  put  up 
without  pins,  merely  folded  deeply  so  as  to  stay  closed. 
Mucilaged  labels  are  very  convenient  and  inexpensive 


144  OPERATING   ROOM 

for  such  dressings.  Flour  paste  is  cheap  and  useful  for 
labels,  made  by  dissolving  a  teaspoonful  of  flour  in  one 
cup  of  cold  water  and  boiling  until  clear. 

Rubber  Gloves. — Gloves  must  first  be  washed  in  cold 
water  to  remove  K-Y,  vaselin  or  blood ;  second,  all  the  air 
squeezed  out  so  that  they  stay  under  water,  then  wrapped 
in  old  muslin  so  as  not  to  stick  to  the  sides  of  the  boiler 
above  the  water  line,  dropped  into  the  boiler,  and  boiled 
for  five  minutes.  The  sterilizing  room  must  have  its 
own  clock,  on  the  wall  behind  the  sterilizers,  in  plain  view 
while  they  are  being  run.  The  gloves  are  lifted  out, 
drained,  tested  for  holes  with  cold  water,  and  hung  on  the 
glove-tree  to  dry.  The  hospital  carpenter  can  make  a 
glove-tree,  like  a  hat-tree,  a  pole  on  a  tripod  with  prongs 
of  wood  the  size  of  a  clothes-pin  and  as  nearly  vertical  as 
possible,  on  which  the  glove  hangs  by  one  finger.  When 
dried  on  one  side  they  are  almost  dry  on  the  other,  but 
are  turned.  Then  they  are  sent  to  the  workroom  in  two 
lots,  those  with  holes  and  those  without,  to  be  mended 
with  "pure  gold"  rubber  cement.  The  holes  are  located 
by  blowing  up  the  glove  and  listening  for  the  escape  of 
air,  wetting  it  slightly  in  a  doubtful  place  to  look  for 
bubbles  (Fig.  19).  To  blow  up  a  glove,  hold  it  taut  by 
both  sides  of  the  wrist  with  forefingers  and  thumbs,  twirl- 
ing it  over,  and  catching  it  all  in  at  the  wrist,  pushing  the 
air  up  into  the  digits.  To  mend,  roughen  the  area  around 
the  hole  with  sandpaper  or  a  nail  file,  cut  the  patch  with 
round  edge,  apply  and  press  firmly  for  a  few  moments  with 
the  warm  hand,  then  lay  in  a  press.  Powdery  gloves  do 
not  take  the  cement.  If  any  portion  of  the  glove  dilates 
too  much,  mark  it  "poor"  and  keep  in  a  class  by  itself. 
To  powder  the  gloves,  shake  a  large  quantity  of  unper- 
fumed  talc  powder  in  a  gallon  basin  set  on  the  work 
table,  and  station  yourself  on  a  high  stool  so  as  to  have 
purchase  when  pressing  downward,  then  pass  the  gloves, 
both  sides,  through  the  powder,  squeezing  them  down  on 
the  unyielding  basin.  Fold  the  cuffs  back  until  they  only 
are  wrist  length  (short),  so  that  the  scrubbed  hands  of  the 


FORMULAE    AND    DIRECTIONS 


145 


surgeon,  none  too  clean  at  best,  surgically  speaking,  do 
not  touch  the  outside  when  putting  them  on.  Match 
the  gloves  for  hands  and  sizes,  then  lay  in  their  cases  and 
envelopes,  marked  as  to  size,  condition,  whether  perfect, 


Fig.  19. — Detecting  holes  in  a  glove. 

poor,  or  mended,  and  for  any  special  surgeon,  and  "dry 
sterilize"  for  twenty  minutes  at  15  pounds. 

One  method  of  packing  gloves  for  sterilizing  includes 
in  one  dressing  cover  the  glove  cases  for  the  chief  operator 
10 


146  OPERATING   ROOM 

and  his  assistants.  Another  method  is  to  put  each  glove 
case  (one  pair)  in  its  own  envelope,  so  that  it  may  do  for 
anyone  who  wears  that  size.  The  scrubbed  nurse's  gloves 
are  done  up  for  her  separately.  If  many  are  put  up  in 
one  bundle,  and  the  chief's,  for  instance,  are  imperfect, 
a  whole  new  set  must  be  unsterilized.  When  a  new  opera- 
tor or  intern  comes  the  nurses  should  at  once  register  the 
exact  size  he  wears,  and  it  is  very  flattering  to  a  surgeon  to 
have  the  proper  size  handed  to  him,  wet  or  dry,  three 
months  later  when  he  again  visits  a  new  hospital.  He 
will  show  his  appreciation.  To  prevent  inaccuracy 
about  gloves  the  nurse  who  mends  them  should  put  them 
in  covers  and  leave  a  signed  slip  inside  each  case.  Put 
a  small  envelope  of  powder  in  with  each  pair  of  gloves. 

Rubber  Tubing. — This  must  be  suited  to  the  various 
wounds  in  length,  lumen  and  firmness,  or  thickness  of 
wall.  Some  pieces  will  be  cut  into  a  T  and  reversed  in 
direction,  therefore  requiring  a  greater  length.  There 
must  be  a  whole  range  of  sizes  in  diameter,  pliability,  and 
length.  If  the  surgeons  at  any  time  let  drop  a  hint  of 
what  they  may  some  day  in  the  future  want  for  special 
cases  it  is  easy  to  keep  it  in  stock.  There  should  be  no 
anxiety  about  it  in  the  surgeon's  mind.  Rubber  does  not 
keep  well  after  three  months.  Do  not  buy  any  with  a 
disagreeable  odor,  made  from  old  goloshes  and  auto- 
mobile tires.  Buy  it  as  pure  as  possible,  considering  the 
firmness.  When  in  reserve  stock,  unprepared,  rubber 
should  be  in  a  cold  place,  dusted  with  lycopodium,  which 
is  blown  out  before  washing  and  boiling.  By  wrapping 
all  rubber  in  old  muslin  no  scum  from  the  water  can  col- 
lect on  it  in  hard  masses.  Boil  for  ten  minutes,  then 
transfer  with  clean  forceps  into  a  clean  boiled  jar  con- 
taining carbolic  acid  solution  (5  per  cent.).  Do  not  cut  a 
catheter  to  get  a  fine  drainage-tube.  Have  the  finest 
tubing  as  well  as  the  largest. 

Catheters,  Filiforms,  and  Bougies. — These  are  kept 
until  used  in  a  cold  place  in  lycopodium  powder.  There 
should  be  made  by  the  hospital  carpenter  a  large  flat  box 


FORMULAE    AND    DIRECTIONS  147 

with  lid  and  padlock,  divided  into  compartments  for  each, 
so  as  to  help  in  instantaneous  selection  or  to  review  the 
stock  as  to  number  of  each  size.  The  nurse  who  has  the 
care  of  these  goods  must  be  informed  when  one  is  taken 
out  to  be  lent  or  used  for  some  special  purpose.  A 
spindle  in  the  workroom  on  the  table  (protected  by  a 
cork),  or  a  bill-file  high  on  the  wall,  will  prove  a  good  way 
to  keep  all  such  memoranda — "Retention  catheter 
(mushroom),  No.  14,  sent  to  Ward  B  for  Mrs.  Mintz." 

Rubber  catheters  should  be  washed  in  cold  water  with 
soap  to  remove  any  lubricant,  then  held  under  the  cold 
tap  and  milked,  as  a  cow's  udder,  to  remove  any  solid 
particles  inside,  then  boiled  in  old  muslin,  and  hung  up 
in  a  cool  place  to  drain.  Catheters  must  always  be 
stretched  to  show  if  they  have  lost  their  resiliency.  A 
catheter  which  is  roughened  or  has  any  cuts  or  slashes 
around  the  eye  must  not  be  used.  Catheters  (rubber)  for 
men  and  women  should  not  be  taken  from  the  same 
place.  To  avoid  this,  use  a  female  rubber  catheter, 
8  inches  in  length,  made  by  at  least  one  great  hospital 
supply  firm.  The  short  length  prevents  its  touching  any 
unscrubbed  part.  The  long  male  catheters  get  twisted 
and  drop. 

Silk  catheters  must  not  be  boiled,  bent,  or  carbolized. 
They  are  of  woven  silk,  covered  with  shellac,  and  must 
be  kept  cool  at  all  times.  They  are  harmful  to  the 
urethral  canal  if  roughened  the  slightest  bit  by  causing 
abrasions  and  stricture.  They  must  be  washed  with 
cold  water  and  a  mild  soap,  such  as  Castile  or  Ivory. 
All  soap  ends  may  be  boiled  down  into  a  fluid  paste  for 
such  purposes.  The  silk  catheters  are  then  drained,  and 
may  be  hung  in  a  small  fumigating  cabinet  to  dry.  Such 
a  cabinet,  suitable  for  electric  non-boilable  apparatus, 
should  be  improvised  at  small  cost;  a  box  with  a  door 
sealed  with  "gumtite"  or  other  gummed  paper  which, 
when  the  articles  are  required,  can  be  turned  with  its 
door  to  the  open  window  to  drive  off  the  fumes  of  for- 
maldehyd  from  the  candles  used  on  the  last  occasion. 


148  OPERATING    ROOM 

Fine  cabinets  for  this  purpose  are  made  by  the  hospital 
supply  companies. 

Filiforms  are  treated  like  silk  catheters.  A  carbolic 
solution  which  would  disinfect  would  ruin  their  texture. 
Some  filiforms  are  olive-tipped — some  are  as  fine  as  a 
horsehair. 

Bougies  are  solid  catheters  of  waxed  silk  or  catgut, 
chemically  treated  so  as  to  be  firm  enough  to  create  a 
passage  or  locate  a  stricture  in  the  urethra. 

Retention  catheters  are  to  be  retained  in  the  bladder,  and 
are  inserted  from  above  in  the  course  of -the  operation, 
or  inserted  at  its  conclusion,  while  the  patient  is  yet 
relaxed,  by  means  of  an  olive-pointed  bougie  or  a  large 
uterine  probe.  No  force  is  employed,  but  much  lubri- 
cant. Very  slender  uterine  dressing-forceps  have  been 
used,  but  it  is  risky  on  account  of  the  numerous  folds  of 
mucous  membrane  in  the  urethra,  and  only  when  the 
patient  is  under  an  anesthetic. 

Preservation  of  Specimens. — When  a  section  is  cut 
out  of  a  growth  to  be  "frozen"  and  examined  imme- 
diately before  proceeding  with  the  operation  there  is  no 
time  to  waste  in  long  journeys  to  a  distant  laboratory. 
Everything  must  be  ready  in  the  workroom,  including  the 
microscope:  (1)  A  watery  solution  of  formalin,  5  per  cent., 
three  to  five  minutes'  immersion;  (2)  50  per  cent,  alco- 
hol, three  minutes;  (3)  absolute  alcohol,  one  minute; 
(4)  wash  off  with  water,  stain,  etc. 

This  is  a  speedy  "combination  freezing  and  fixation" 
method  by  Dr.  Thomas  Cullen  of  the  Johns  Hopkins 
Hospital.  It  is  the  nurse's  duty  to  provide  the  stock  mate- 
rials and  utensils,  graduates  of  all  sizes,  marked  in  the 
metric  system,  and  a  place  where  the  pathologist  has 
suitable  light  for  his  work. 

Black  Rubber  Hard  Goods. — These  must  be  kept  in 
cotton-lined  boxes,  so  as  not  to  chip  or  break.  If  rough- 
ened they  would  destroy  the  part  where  they  are  placed. 
They  are  cleansed  by  cold  water,  soap,  bottle  or  tube 
brushes,  and  carbolic  acid,  5  per  cent.  Black  hard 


FORMULAE    AND    DIRECTIONS  149 

rubber  must  not  be  boiled,  or  the  shape,  as  of  a  trache- 
otomy tube,  is  ruined. 

Silver  Leaf. — This  is  bought  in  books,  of  silver  in- 
terleaved with  paper  (Fig.  20).  This  book  should  be 
cut  into  sections,  each  containing  five  sheets  of  silver. 
Each  booklet  is  then  protected  by  two  sheets  of  heavy 
cardboard,  the  whole  being  wrapped  in  a  double  muslin 
cover,  pinned,  and  marked  for  sterilization  for  twenty  min- 
utes at  15  pounds.  In  a  general  way,  all  clean  articles, 
such  as  silver  leaf,  which  cannot  be  boiled  and  are  not  used 


HALSTED'S 

SILVER 
FOIL 


Fig.  20.— Silver  foil. 

again,  are  sterilized  for  twenty  minutes  at  15  pounds.  It 
is  a  very  lazy  method  to  keep  all  the  silver  in  one  book, 
and,  besides,  it  causes  exposure  to  the  infection  from  in- 
struments used  in  a  wound. 

Care  of  Instruments. — After  operations  count  each 
kind  and  classify  into  (1)  Needles — straight,  curved,  etc.; 
(2)  knives;  (3)  scissors;  (4)  blunt  instruments. 

Collect  in  separate  basins,  and  if  one  is  missing,  get  it — 
if  the  patient  has  to  be  reopened — immediately.  Wash  in 
cold  water  and  prepare  to  boil  as  follows:  (1)  Fasten  the 
needles  in  gauze  with  two  bites  each;  (2)  fold  the  knives 


150  .  OPERATING    ROOM 

and  scissors  into  old  muslin,  each  in  a  layer  by  itself; 
(3)  drop  in  the  blunt  instruments;  (4)  drop  in  the  sharp- 
edged  instruments  according  to  the  house  rules  of  the 
Medical  Board,  or  place  in  carbolic  acid,  then  pure  alco- 
hol, for  the  time  required;  (5)  add  a  handful  of  vmshing 
soda  (sodium  carbonate)  when  boiling  instruments  (a)  to 
soften  the  water;  (b)  to  raise  the  temperature  and  facilitate 
sterilization;  (c)  to  prevent  rust. 

When  boiled,  lift  out  on  the  tray,  drain,  and  prepare 
to  polish.  Use  a  thick  pine  board,  1|  by  1  ft.  by  1  in., 
having  a  headpiece  to  work  against  and  a  place  for 
brushes  and  Bon  Ami.  Superannuated  tooth-  and  nail- 
brushes, well-boiled  flat  wide  corks,  pieces  of  gauze  and 
flannelette  are  best  for  instruments  in  getting  at  the 
crevices  and  corrugations.  This  is  the  time  to  see  whether 
they  need  renickelling.  Wash  off  thoroughly  in  a  lathery 
solution  of  tincture  of  green  soap  and  at  once  transfer  to 
a  basin  of  alcohol.  A  pint  of  alcohol  may  be  used  over 
and  over  again  in  this  way,  being  at  other  times  tightly 
corked  and  definitely  labelled.  The  corrugations,  joints, 
and  locks  are  well  lubricated  with  vaselin  after  the  in- 
struments are  thoroughly  dried.  Needles  are  threaded 
with  suitable  silk  and  run  in  flannel,  scissors  and  other 
instruments  laid  systematically  on  the  shelves,  and 
knives  laid  in  their  boxes.  Calcium  chlorid  in  the 
cabinet  absorbs  moisture  and  camphor  prevents  oxy- 
genation  of  the  silver  probes  and  catheters. 

How  to  Care  for  Rubber  Utensils  (Soft).— Rubber 
aprons  are  soaked  in  bichlorid  of  mercury  (1  :  1000) 
before  operation.  After  operation  they  are  scrubbed  with 
cold  water,  brown  soap,  and  a  brush,  rinsed  with  plain 
water,  and  painted  with  carbolic  acid  solution,  5  per  cent., 
then  dried  over  a  bar  and  powdered.  All  flat  rubber 
should  be  rolled  on  a  roller  under  the  edge  of  a  counter  or 
shelf;  the  roller  of  a  window-shade  can  be  adjusted  for 
this.  Rubber  douche  bags,  seldom  used  now,  can  be  boiled, 
and  after  using  hung  upside  down  to  drain. 

How  to  Prepare  Sterile  Adhesive. — Cut  the  strips  the 


FORMULA    AND    DIRECTIONS  151 

desired  length  and  width,  roll  on  a  wide-mouthed  bottle 
(single  thickness),  and  sterilize  in  the  dressing  sterilizer 
in  a  double  muslin  cover.  When  needed  they  may  be 
easily  loosened  by  pouring  hot  sterile  water  in  the 
bottle,  beginning  first  by  tempering  it  with  a  little  cold 
water. 

To  obtain  a  fine  line  of  union  without  the  possibility  of 
stitch  abscesses  certain  surgeons  use  adhesive  edged  with 
hooks  and  eyes.  Sew  the  hooks  and  eyes  on  two  strips  of 
white  1-inch  tape  at  the  proper  distances  for  a  length  of 
8,  10,  or  12  inches,  to  be  slightly  longer  than  the  char- 
acteristic incision  made  by  your  surgeon.  Cut  sheets  of 
adhesive  the  same  length  and  6  inches  wide.  Leave  the 
crinoline  on  all  but  one  side,  where  it  is  removed  at  a  dis- 
tance of  1  inch.  Plaster  the  hooks  and  eyes  on,  tape  down, 
into  position,  slightly  turning  in  the  edge  of  the  adhesive. 
Face  the  bare  inch  surfaces  with  adhesive,  its  edge  also 
turned  in  a  little.  Overcast  the  edge  down  among  the 
hooks  or  eyes.  Then  remove  the  crinoline  and  plaster  the 
two  sheets  side  by  side  on  a  large  brown  gallon  bottle. 
Do  up  in  a  double  muslin  cover  and  sterilize  as  above. 

Ivory-handled  Eye  Knives. — These  must  not  be 
boiled.  They  may  be  disinfected  in  benzine  or  formalin 
and  rinsed,  then  wiped  dry. 

Needles  with  a  Lumen  or  Bore. — All  hollow  needles  for 
aspirating  or  hypodermic  use,  after  being  boiled,  should 
be  held  in  forceps  over  an  alcohol  flame.  This  dries  with- 
out discoloration.  Then  insert  the  dry  oiled  stylet. 
Never  put  away  a  needle  or  trocar  without  its  stylet. 

Glass  Syringes. — Ground-glass  syringes  are  sterilized 
by  boiling  in  separate  parts.  After  they  are  boiled  and 
cooled  and  wet  again,  insert  the  plunger  in  the  barrel. 
They  must  be  thoroughly  washed  before  boiling. 

Tracheotomy  Tubes. — When  a  tracheotomy  tube  is 
in  situ  it  is  best  cleaned  by  pheasants'  feathers,  which 
are  firm  yet  flexible  and  pointed.  They  should  always  be 
on  hand.  The  whole  apparatus  is  covered  with  gauze 
moistened  in  soda  bicarbonate  solution. 


152  OPERATING   ROOM 

Hospital  Cold  Cream. — For  the  anesthetic  room  some 
cream  is  needed  for  patients  who  fear  the  use  of  vaselin, 
etc.: 

White  wax 5  iv. 

Spermaceti Siv. 

Liquid  petroleum  (white  mineral  oil) §xxxij. 

Sodii  borate  (borax) §ss. 

Rosewater 5 xvj. 

Melt  the  wax,  spermaceti,  and  oil  together  at  a  very  moderate 
heat.  Dissolve  the  borax  in  the  rosewater,  then  warm  this  solution 
and  add  it  to  the  melted  waxes  and  oil,  and  stir  briskly  until  cool  and 
creamy. 

Hospital  Hand  Lotion. — 

Powdered  tragacanth 5j- 

Alcohol 5ss. 

Mix  together  and  quickly  add  1  pint  of  water  and  stir  briskly. 
Add  1  ounce  of  glycerin  and  2  ounces  of  alcohol  and  add  water  to 
make  1  quart. 
Perfume  to  suit. 

To  Sterilize  Vaselin. — Sterile  vaselin  is  prepared  by 
setting  the  container  in  a  water-bath  and  putting  a 
dairy  thermometer  in  the  vaselin,  raising  it  to  212°  F., 
and  keeping  it  at  that  point  for  an  hour.  The  lid  is  boiled 
beside,  but  not  on,  the  container.  To  obtain  sterile  .vaselin 
from  such  a  jar  afterward  dip  in  a  sterile  grooved  direc- 
tor that  has  not  been  included  on  the  instrument  table. 
Do  not  put  in  the  gloved  finger.  The  grooved  director 
may  be  then  drawn  over  a  sterile  compress  or  applied  to 
the  glove.  One  can  judge  by  the  surface  being  intact 
that  the  vaselin  is  sterile  This  should  be  done  daily  in 
cases  of  constant  catheterization,  etc. 


CHAPTER  XI 
THE  METRIC   SYSTEM.     SOME  BRIEF  NOTES 

LENGTH 

THE  basis  of  the  metric  system  is  the  unit  of  length. 
From  it  are  worked  out  the  units  of  the  second  and  third 
dimensions,  and  of  capacity  and  weight,  by  combining 
certain  facts  in  physics,  relating  to  temperature,  or  density 
at  certain  times.  In  order  to  have  a  distance  that  would 
be  international  and  non-disputable,  when  changing  their 
system  of  measures  the  French  took  for  a  unit  that 
measure  which  is  one  ten-millionth  of  the  distance  between 
the  equator  and  the  North  Pole,  or  39.37  inches,  a  little 
longer  than  1  yard,  and  called  it  a  meter. 

To  get  smaller  units  of  length  (one  dimension)  they 
divided  the  meter  into  10,  100,  etc.,  equal  parts,  using 
Latin  prefixes  to  denote  diminution: 

Meter  =  39.37  inches  (more  than  1  yard). 

Decimeter     =    3.937  inches  (about  |  foot). 
Centimeter  =       .3937  inch  (cm.  =  about  f  inch). 
Millimeter    =       .03937  inch  (mm.  =  about  ^  inch). 

To  get  larger  units  of  .length  they  increased  the  meter 
to  10,  100,  etc.,  times  its  length,  using  Greek  prefixes  to 
denote  multiplication: 

Meter  =        39.37  inches. 

Decameter    =?      393.7  inches. 
Hectometer  =    3937  inches. 
Kilometer     =  39370  inches  (about  f  mile). 

SQUARE   MEASURE 

Square  measure  is  derived  from  this  unit  of  length,  the 
meter,  since  we  multiply  length  by  length  to  get  area. 
If  a  plot  of  ground  is  5  meters  long  and  4  meters  wide  it 
contains  5  X  4  =  20  square  meters. 

153 


154  OPERATING   ROOM 

CUBIC   MEASURE 

Cubic  measure  for  wood,  loads  of  earth,  etc.,  is  also 
derived  from  this  unit  of  length,  the  meter,  since  we 
multiply  length  by  breadth  by  thickness  (all  being 
distances  in  meters,  etc.)  to  get  volume  of  earth  and  other 
materials  for  building,  etc. 

If  a  load  of  earth  is  16  decimeters  long  (16  X  i  foot  = 
4  feet)  by  12  decimeters  wide  (12  X  i  foot  =  3  feet)  by 
8  decimeters  deep  (8  X  i  foot  =  2  feet),  the  whole  load 
then  contains  16X1 2X8=  1536  cubic  decimeters,  or 
4  feet  X  3  feet  X  2  feet  =  24  cubic  feet. 

If  1  decimeter  of  length  =  about  J  foot,  then  1  cubic 
decimeter  =  J  foot  length  X  i  foot  breadth  X  i  foot 
depth  (or  thickness)  =  A  cubic  foot.  1f'|-  =  24  cubic 
feet. 

VOLUME 

Volume  is  the  measure  for  water  and  many  other  mate- 
rials requiring  a  different  kind  of  utensil.  A  cubic  centi- 
meter is  a  mass  of  water  that  has  the  following  propor- 
tions : 

Length 1  centimeter  (.3937  inch,  or  about  f). 

Width 1  centimeter  (.3937  inch,  or  about  f ). 

Thickness.  , 1  centimeter  (.3937  inch,  or  about  f). 

A  cubic  centimeter  has  three  dimensions  and  is  the  same 
size  in  every  direction,  appearing  as  follows, 


only  greatly  reduced,  since  each  side  would  be  only  f  inch 
long. 

The  cubic  centimeter  has  been  taken  as  the  unit  or 
starting-point  for  measuring  fluids,  such  as  normal  saline, 
blood,  etc. 


THE    METRIC    SYSTEM.    SOME    BRIEF    NOTES  155 

There  are  1000  cubic  centimeters  in  1  quart,  which 
corresponds  to  the  French  liter. 

There  are  500  cubic  centimeters  in  1  pint. 

One  pint  =  16  ounces  =  128  drams  =  7680  minims, 

5^<r  of  7680  =  about  15  minims. 

One  cubic  centimeter  =  15  minims  approximately. 

WEIGHT 

In  order  to  get  a  unit  of  weight  the  mathematicians 
then  took  1  cubic  centimeter  of  distilled  water  at  4°  C., 
its  thickest  or  densest  period,  and  calling  its  weight 
(15  grains)  1  gram,  made  that  the  standard  or  starting- 
point  for  all  substances  that  are  weighed.  They  used 
the  same  Latin  prefixes  to  denote  diminution. 

1  gram  =15  grains  Troy,  dry  weight. 

1  decigram  =     1.5  grains  Troy,  dry  weight,  or  1^  grs. 

1  centigram  =       .15  grain  Troy,  dry  weight,  or  j\,  gr. 

1  milligram  =       .015  grain  Troy,  dry  weight,  or  2g0  gr. 

To  denote  increase  or  multiplication  of  weight  Greek 
prefixes  were  used: 

Decagram  =  150  grains  Troy,  dry  weight,  about  &  oz. 
Hectogram  =  1,500  grains  Troy,  dry  weight,  about  3|  oz. 
Kilogram  =  15,000  grains  Troy,  dry  weight,  about  2  Ibs. 

1  pound          =  16  ounces '=  128  drams  =  7680  grains. 

2  pounds         =  7680  X  2  =  15,360  grains. 

15,360 

~1f>nn    grs.      =15  grains  approximately. 
1UUU 

It  is  not  absolutely  true  of  all  drugs,  but  approximately 
speaking,  minims  (wet)  weigh  as  much  a3  grains  (dry), 
and  that  is  the  cause  of  the  coincidence  in  the  15. 

SUBSTANCES  MEASURED  IN 

Minims.  Grains. 

Saline.  Powders. 

Oils.  Salt. 

Blood.  Silver  nitrate  (solid). 

Tincture  of  iqdin.  Argyrol  (dry,  solid),  etc. 

Tincture  of  digitalis,  etc. 


156  OPERATING   ROOM 

It  may  be  of  interest  to  note  that  the  original  meter  is 
the  distance  between  two  lines  on  an  actual  platinum- 
iridium  rod  preserved  in  the  archives  of  the  International 
Metric  Commission  at  Paris.  Many  European  countries 
have  adopted  the  metric  system,  thus  facilitating  all  forms 
of  international  relations,  but  it  is  especially  suited  to  the 
scientists,  who  thus  have  one  common  and  delightfully 
systematic  medium  of  communication. 


CHAPTER  XII 

SPECIAL  DRESSINGS 

Mastoid  Tips. — Gauze  comes  in  100-yard  pieces  in 
folds  1  yard  square.  In  cutting  dressings  it  is  most 
economic  to  cut  this  large  fold  in  the  center,  and  then 
pick  up  each  and  open  it  out  for  1-yard  squares  fluffed. 
But  for  small  dressings,  where  we  wish  to  keep  the  whole 
pile  flat,  layer  upon  layer  for  at  least  twenty  thicknesses, 
we  cut  off  the  folded  edges  (ten)  very  sparingly,  keeping 
the  pieces  to  fill  pads  for  perineal  wear.  Then  the  large 
square  is  cut  in  sixteen  equal  parts,  four  to  each  side. 
These  small  squares  are  now  laid  all  on  one  pile  and  made 
into  tips  in  the  following  manner: 

(1)  Pull  one  piece  off  the  pile  with  the  left  hand. 

(2)  Catch  it  by  the  right  forefinger  and  thumb  in  the 
very  center  and  pull  it  through  the  left  hand,  which  is 
closed  over  it. 

(3)  Lay  it  to  the  right  in  a  pile,  with  the  nose  pointing 
away  and  the  ragged  ends  nearer. 

(4)  When  about  a  thousand  are  made,  pick  them  up 
with  the  right  hand,  place  the  noses  in  an  even  row  or 
cluster,  turn,  and  trim  off  the  ragged  ends  with  one  cut  of 
large  bandage  scissors,  leaving  the  tips  6  inches  long. 

(5)  Put  up  in  double  muslin  covers  in  bundles  of  thirty 
or  so. 

Mastoid  Dressing. — Arrange  for  sterilization  in  the 
double  muslin  square  covers  and  put  in  as  follows: 

(1)  A  square  of  blue  tissue  off  cotton  to  keep  fluff  off 
the  cover. 

(2)  A  square  of  cotton  6  inches  each  way  for  an  adult, 
then  blue  tissue,  then  another-  square  of  cotton. 

(3)  A  piece  of  plain  gauze  packing,  9  inches  long  and 
|  inch  wide  (being  perfectly  sterile,  not  on  the  table). 

157 


158  OPERATING   ROOM 

(4)  A  gauze  roller  bandage  of  the  finest  quality,  2 
inches,  the  sizing  sets  it  when  wet  a  little  on  the  outside. 

Gant  Pad. — Used  for  hemorrhoidectomy  or  prolapsed 
rectum.  Make  the  usual  flat  folded  compresses,  each 
one-fourth  of  the  large  gauze  square  yard.  With  all  the 
raw  edges  turned  in,  these  are  4J  inches  square,  as  meas- 
ured up  to  the  patterns  cut  or  lined  on  the  work-table. 
Take  two  compresses  and  cut  each  in  half.  Turning  in 
that  raw  edge,  fold  the  first  half-piece  in  four  equal  layers, 
the  second  in  five,  the  third  in  six.  Roll  the  fourth  in  a 
tight,  hard  roll,  keeping  tight  with  a  safety-pin  tempo- 
rarily in  the  center.  Lay  them  in  a  pile  one  above  the 
other,  making  a  sort  of  pyramid  or  wedge.  With  two 
strips  of  adhesive,  each  6  inches  long  and  f  inch  wide, 
wind  the  two  ends  of  the  pile  tightly.  This  causes  the 
bottom  layer  to  lie  flat  and  each  one  above  it  to  bulge. 
When  the  whole  is  laid  with  its  convex  side  against  the 
anus,  the  flat  side  being  pressed  in  by  a  binder,  the  bulg- 
ing edge  is  made  still  more  convex.  By  being  well  lubri- 
cated it  forms  a  good  dressing  for  a  prolapsed  rectum, 
being  held  in  place  with  stout  adhesive  straps  from  but- 
tock to  buttock. 

"Whistle,"  or  Tampon  Canula. — This  prevents  oozing 
of  blood  by  pressure  after  hemorrhoidectomy,  permits 
any  considerable  hemorrhage  to  show  itself  in  the  outer 
dressings,  the  painless  escape  of  flatus,  or  introduction  of 
enemata.  Take  a  piece  of  stiff  rubber  tubing  3  inches 
long,  smear  with  sterile  vaselin,  and  wrap  around  with 
plain  gauze,  vaselin  being  rubbed  into  every  turn  of  the 
cloth.  Wind  the  gauze  spirally  at  what  will  be  the  intro- 
duced or  proximal  end,  so  that  it  presents  the  form  of  a 
truncated  cone.  Slip  a  large  safety-pin  through  the  distal 
end  so  that  it  cannot  entirely  enter  the  rectum.  Follow 
with  split  gauze  compress  pad  and  T-binder. 

"Canule  a  Chemise"  (Petticoated  Tube).— The  gauze  is 
gathered  about  the  end  of  a  piece  of  rubber  tubing,  just 
like  the  cloth  of  an  umbrella  at  the  ferrule  of  an  umbrella, 
hanging  down  from  it  loosely  like  the  unbound  umbrella. 


SPECIAL    DRESSINGS  159 

The  tight  end  is  introduced  into  the  rectum,  the  loose 
part  acting  as  a  drain  or  a  fluffy  pressure  pad,  all  being 
well  smeared  with  sterile  vaselin. 

Leg  Rolls. — The  selvedge  must  be  cut  off  so  as  to  pro- 
duce a  softly  yielding  spiral  when  applied.  Cut  off  in 
one  piece  three  thicknesses  of  the  yard-square  gauze. 
Fold  over  so  that  the  selvedges  come  together  and  trim 
them  off  very  sparingly,  then  cut  in  two,  down  the  central 
fold,  making  thus  two  pieces  J  yard  wide  and  3  yards  long. 
Open  out,  turn  the  ends  in  about  2  inches,  fold  almost  to 
the  center,  and  fold  over,  making  a  strip  4J  inches  wide. 
Hold  squarely  on  a  solid  table  and  roll  very  evenly. 
Do  up  in  packages  of  two. 

Tampons. — Required,  lambs'  wool  or  best  grade  of  cot- 
ton, smooth  stout  cotton  cord  (knitting  cotton  No.  4), 
and  the  medications  desired.  Cut  the  cotton  or  wool  in 
squares  4|  inches  each  way.  Roll  fairly  snug  and  throw 
twice  around  the  center  or  waist  a  doubled  twine,  work- 
ing with  the  folded  end  of  it.  Pass  the  loose  ends  through 
the  noose  and  tighten,  then  steep  in  the  medication  or- 
dered. For  a  very  young  woman  tampons  may  be  made  as 
follows:  Cotton  1  inch  square  and  only  about  J  inch  thick, 
wind  with  noose  around  the  center,  bring  the  ends  to- 
gether at  the  right  and  left  to  cover  the  cord,  and  trim 
until  perfectly  round  and  even,  like  balls  of  wool  in  fancy 
work  used  as  round  tassels.  If  not  medicated,  tampons 
should  be  lubricated. 

Small  Sponges. —  The  Best  Way. — Cut  the  gauze  in 
9-inch  squares  by  first  trimming  off  the  edges  of  the  flat 
yard  folds;  second,  cutting  each  side  into  four  equal 
parts,  sixteen  to  the  whole  square  yard.  Having  all  these 
9-inch  squares  in  one  pile  squarely  in  front  of  one,  place 
the  upper  left-hand  corner  down  on  the  lower  right-hand 
corner,  making  a  triangle.  Place  the  left  hand  in  anatomic 
position,  palm  upward,  on  the  gauze  and,  enclosing  the 
first  three  fingers  in  it,  bring  the  two  long  points  (of  the 
fold)  and  the  third  remaining  point  down  into  the  palm 
in  a  line  with  the  fold  in  one  big  soft  but  secure  twist. 
Secure  it  with  the  thumb  and  gently  turn  inside  out, 


160  OPERATING   ROOM 

Cloth  Retractors. — These  are  intended  to  hold  the  soft 
parts  out  of  the  way  during  an  amputation  while  the 
bone  is  actually  sawed.  A  piece  of  stout  unbleached 
muslin,  2  feet  long  and  1  foot  wide,  is  torn  lengthwise 
half-way  into  two  or  three  tails,  put  up  in  a  double  cover, 
and  sterilized.  Two  tails  are  proper  for  the  humerus  or 
femur,  three  tails  (leaving  the  middle  narrow  tail  for  the 
interosseous  space)  in  the  forearm  or  leg  (each  of  which 
has  two  bones). 

Bandaging. — Every  nurse  should  be  able  to  apply  any 
bandage  with  the  edges  turned  in  and  to  be  handy  with 
needle  and  thread  when  stitching  it  in  position. 

Making  Packing. — Use  the  best  gauze  bandages. 
Sit  with  the  right  foot  on  a  low  stool.  Turn  in  the  end  of 
the  bandage,  then  turn  each  edge  in  toward  the  center. 
Then  fold  the  two  folds  together  so  as  to  make  the  final 
strip  one-quarter  the  original  width.  Roll  the  first  few 
inches  with  both  hands  into  a  tape-like  roll.  Then  pin 
securely  as  much  as  is  finished.  Then,  holding  the  raw 
bandage  in  the  left  and  the  finished  roll  in  the  right,  turn 
the  edges  in  to  the  center,  and  again,  together  with  a 
sawing  motion  over  the  knee,  aided  by  the  fingers  of  the 
left  and  applying  traction  with  the  right.  Pin  securely, 
after  rolling  up  with  the  right  steadily,  every  few  inches. 
Two  pins  will  do,  alternating  like  cribbage  pegs. 

Eye  Pads. — To  prevent  ether  eyes  cut  a  piece  of  gauze 
8  inches  square.  Fold  it  on  itself  laterally.  Leaving  a 
space  of  \  inch  in  the  center,  bounded  by  vertical  stitching, 
pad  it  to  fill  in  the  hollows  of  the  eyes  and  nose,  so  that 
when  it  is  laid  on  the  face  the  eyes  will  be  protected 
from  any  random  drops. 

Aristol  Pledgets. — Take  a  very  thin  shred  of  the  finest 
absorbent  cotton  and  pick  it  until  it  is  a  circle  f  inch  in 
diameter,  then  gather  all  the  edges  in  to  the  center  and 
-lay  it  on  a  smooth  glass  slab,  rolling  it  with  the  ends  of 
the  second  and  third  fingers,  the  palm  facing  downward, 
and,  as  when  playing  the  piano,  perfectly  horizontal. 
With  practice  these  can  be  rolled,  like  the  opium-smoker's 


SPECIAL    DRESSINGS  161 

"pills,"  into  perfect  balls.  When  a  large  number  of  this 
and  gradually  smaller  sizes  are  rolled  they  are  then  stirred 
about  in  a  square  glass  basin  containing  a  couple  of  drams 
of  aristol  until  they  carry  all  they  can.  They  are  then 
sterilized  in  a  jar. 

Applicators. — (The  soiled  cotto'n  on  any  applicator 
must  always  be  removed  by  a  bit  of  fresh  cotton.  Note!) 
The  applicators  must  be  rolled  so  that  the  part  used  can 
be  easily  removed.  Take  a  thin  shred  of  cotton  about 
1  inch  square,  of  an  even  thickness,  and,  laying  the  end 
of  a  long  (6-inch)  double  ear  applicator  (wooden)  in  the 
center  of  it  roll  the  cotton  trumpet  shaped,  fastening  it 
with  moderate  firmness  at  the  base.  Wind  both  ends  of 
wooden  applicators,  place  in  glass  tubes  (open  at  both 
ends),  cover,  and  sterilize.  With  toothpick  applicators 
the  ends  are  so  weak  that  about  J  inch  must  always  be 
broken  off  smoothly  lest  it  break  in  the  patient.  The 
best  toothpicks  are  of  pine  or  cedar  and  are  rather  rough 
and  square  in  the  thickest  part  of  their  body;  not  the 
polished,  rounded,  fashionable  cafe  toothpick.  The 
rougher  surface  holds  the  cotton.  Take  a  very  thin 
shred  of  finest  absorbent,  pick  it  to  a  square,  fold  it  like 
a  diaper  once,  then  lay  the  point  of  the  toothpick  in  the 
middle  of  it  and  roll,  finishing  by  running  the  thumb-nail 
around  the  base.  Then,  to  make  it  pretty  and  smooth, 
revolve  it  with  the  right  hand,  holding  the  cotton  head 
between  the  tips  of  the  thumb  and  second  finger  of  the 
left  hand,  pressing  down  from  above  gently  with  the  tip 
of  the  forefinger  to  polish  and  bevel  it  into  the  shape  of  a 
trumpet.  These  are  thrown  away  after  using,  and  being 
inserted  into  infants'  ears  or  nostrils,  the  cotton  must  not 
come  off. 

Tape  Stickers. — These  must  be  made  according  to  the 
drainage  cases.  For  a  back,  use  a  piece  of  basswood  splint, 
9  inches  long  and  3  inches  wide.  Use  the  adhesive  rolls; 
the  cheaper  way  to  buy  it  and  suited  to  all  purposes. 
Nick  the  end  of  the  roll  in  3-inch  widths  ready  to  tear, 
and  tear  the  strips  one  at  a  time,  cutting  them  off  below. 
11 


162  OPERATING   ROOM 

Then  carefully  strip  off  the  crinoline,  of  which  part  is  to 
be  used  again.  At  one  end  fold  down  one  corner  squarely 
on  itself,  a  little  past  the  center  (about  If  inches),  then 
the  other  corner  on  top  of  it,  making  an  even  edge  where 
they  meet.  This  overlapping  made  by  folding  past  the 
center  gives  three  thicknesses  to  cut  through  for  the  tape. 
Now  fold  this  point  on  itself,  and  in  the  center  make  a 
V-shaped  nick  all  the  way  through.  Then  lay  the  strip 
on  the  basswood  splint,  gummy  side  to  the  wood,  so  that 
the  ends  are  flush  and  they  adhere  for  4  inches.  Fold  back 
on  itself  and  apply  the  crinoline  to  the  remaining  space 
as  far  as  the  double  tip.  Take  now  9-inch  lengths  of 
f-inch  white  tape,  make  a  nick  or  opening  1  inch  from 
the  end,  running  not  crosswise,  but  with  the  length  of  the 
tape,  slip  the  short  end  through  the  hole  in  the  adhesive, 
then  thread  its  long  end  through  its  own  eye.  Make  a 
number,  adhering  thus  in  the  first  4  inches  of  their  length, 
crinolined  in  the  center,  folded,  and  threaded  with  tape, 
six  to  a  splint. 

How  to  make  a  T-binder  in  a  hurry  from  a  bandage  of 
muslin:  Cut  off  1  yard  of  a  3-inch  muslin  bandage.  Fold 
it  crosswise  by  its  length  and  slit  it  for  J  inch,  the  cut 
running  lengthwise  with  the  cloth.  Take  a  second  piece 
1  yard  long  and  3  inches  from  the  end,  fold  it  over  length- 
wise, slitting  it  crosswise  for  1  inch.  Thread  this  short  bit 
through  the  cut  in  the  middle  of  the  waistband,  the  first, 
then  thread  the  long  remaining  stem  of  the  T  (which  goes 
between  the  thighs)  through  its  own  eye,  For  a  male 
patient  split  this  latter  for  J  yard  up  from  the  other  end, 
the  bottom  of  the  T,  to  secure  the  dressings.  This  saves 
safety-pins. 

Whether  the  supplies  are  made  by  probationers  in  a  big 
supply-room  or  by  the  nurses  of  the  operating  room,  they 
must  be  supervised  by  the  head  nurse  of  the  operating 
room.  This  unifies  the  work  of  the  house,  and,  in  any 
event,  the  pupil  finishing  her  operating-room  service 
should  know  all  there  is  to  be  known  about  making 
dressings. 


CHAPTER  XIII 

TERMS   USED   IN   SURGICAL  DIAGNOSIS 

THE  pupil  is  humanely  curious  about  the  cause  for 
bringing  each  patient  under  the  knife,  and  we  should 
use,  not  neglect,  to  our  own  great  advantage  this  most 
potent  agent,  indeed,  for  inducing  many  to  "sign  up" 
for  three  years'  training,  to  get  an  insight  into,  not 
anatomy,  but  pathology,  in  which  oddly  enough  no 
primer  has  been  written  yet  for  nurse  training-schools. 
The  pupil  is  entitled  to  know  the  diagnosis,  if  that  has 
already  been  explicity  made,  before  she  attempts  to  "set 
lip"  for  the  operation.  When  it  is  all  over,  and  the  pa- 
tient is  ready  for  the  ward,  the  unscrubbed  nurse  draws 
up  a  slip,  attached  to  his  chart  temporarily,  on  which  are 
blanks  for  the  diagnosis,  operation,  stimulation,  etc. 
(See  chapter  on  Nomenclature.)  She  must,  therefore, 
be  familiar  with  the  sound  and  the  meaning  of  the  terms 
required,  so  as  to  transmit  them  properly  to  her  co- 
workers  on  the  wards  and  so  as  to  enable  all  to  carry  on 
their  work  more  intelligently  and  happily.  In  the  tense 
moments  between  two  cases  it  is  maddening  for  the 
supervisor  to  hear  a  dazed,  "I  beg  your  pardon.  What 
did  you  say  the  diagnosis  was?"  or  "How  do  you  spell 
that?"  But,  again,  it  is  very  easy  to  peep  at  a  text-book 
nearby  in  a  moment's  pause  to  look  up  a  term  one  has 
just  heard  fall  from  the  surgeon's  lips,  the  image  of  the 
thing  discussed  now  engraved  forever  on  one's  mind  be- 
cause the  specimen  is  "right  there"  for  observation.  So 
closety  are  these  terms  of  diagnosis  connected  with  the 
minor  outlying  conditions  that  accompany  the  central 
disturbance,  with  the  names  of  measures  employed  to 
remedy  them,  and  with  the  specific  term  for  the  specific 

163 


164  OPERATING   ROOM 

operation,  that  the  following  list  of  definitions  does  not 
try  to  separate  the  three  classes.  All  may  be  heard  in  one 
conversation  and  in  a  simple  work  of  this  kind  it  would 
be  foolish  to  draw  up  a  third  dictionary,  since  it  causes 
too  much  hurried  fumbling.  There  are  in  the  following 
text  no  terms  not  commonly  used,  but  it  is  attempted  to 
give  a  comprehensive  list  of  all  that  will  be  used  relating, 
not  to  what  is  done  in  the  operating  room  (see  chapter  on 
Nomenclature),  but  relating  to  the  conditions  preceding 
and  necessitating  the  operation. 

Pathologic  tissue  means  diseased  tissue,  in  this  in- 
stance to  be  treated  surgically.  It  may  be  diseased  by  in- 
flammation, benign  or  malignant  tumors,  cysts  of  a  watery 
or  purulent  nature,  malformations,  transformations,  con- 
genital absences  of  parts  and  other  deformities,  besides 
those  resulting  from  accidents  and  wounds.  All  terms 
ending  in  itis  denote  inflammation  of  the  part  named,  as 
cholecystitis,  inflammation  of  the  gall-bladder. 

TABLE  OF  TUMORS 

Normal  tissue.  Tumors  found  therein. 

Fibrillar  connective  tissue.  .  , .Fibroma  singular, 

fibromata  plural. 
Greek  nouns  ending 
in  oma  form  plural 
by  adding  ta. 

Mucous  tissue Myxoma. 

Embryonic  connective  tissue Sarcoma. 

Endothelial  tissue .  Endothelioma. 

Fat  tissue Lipoma. 

Cartilage .Chondroma. 

Bone. Osteoma. 

Neuroglia Glioma. 

Muscle  tissue  type. Myoma. 

Smooth  muscle  tissue. Leiomyoma. 

Striated  muscle  tissue. . .  . . Rhabdomyoma. 

Nerve  tissue Neuroma. 

Vascular  tissue  (veins  and  arteries) Angioma. 

Lymph  vessels Lymphangioma. 

Glands Adenoma. 

Various  forms  of  epithelial  cells  and  asso- 
ciated tissues. . .  .  .Carcinoma. 


TERMS    USED    IN    SURGICAL   DIAGNOSIS  165 

CYSTS 

Cysts  are  sacs  filled  with  watery,  purulent,  or  cheesy 
material,  and  are  of  two  kinds :  (I)  Those  developed  from 
pre-existing  cavities.  (II)  Those  originating  independ- 
ently after  pathologic  changes. 

Class  I  is  formed  by  an  accumulation  in  a  gland  or  its 
excretory  ducts  of  secretion  (altered  somewhat)  when 
pressure  or  inflammation  hinders  normal  discharges. 
This  secretion  is  either  mucous,  sebaceous,  or  serous. 
To  these  belong  the  comedone,  milium,  ranula,  chalazion, 
atheroma,  milk  cyst,  ovarian  cyst,  cysts  of  fallopian 
tubes,  of  gall-ducts,  the  transudation  cysts  due  to 
chronic  inflammation  in  the  lymph-spaces  or  serous 
sacs — namely,  ganglia,  hydrocele,  and  hematocele. 

Class  II  is  formed  (1)  by  the  softening  and  disintegra- 
tion of  tissue  (e.  g.,  from  old  abscesses) ;  (2)  or  by  the  for- 
mation of  a  wall  around  foreign  bodies  (parasites,  masses  of 
blood  producing  an  inflammation  and  becoming  encapsu- 
lated); (3)  or  by  new  growths  in  whose  spaces  various 
kinds  of  fluid  accumulate,  quite  like  glands,  as  adenomata 
on  the  ovaries,  though  they  are  called  cystomata;  (4)  or 
congenital  cysts,  dermoid  cysts  of  the  ovary  or  of  sub- 
cutaneous tissue  (as  the  scalp),  being  probably  part  of 
another  fetus. 

GLOSSARY  OF  TERMS 
A 

Abortion.  Expulsion  of  the  contents  of  the  pregnant 
uterus  before  the  child  is  viable  (end  of  sixth  month). 

(1)  Abdominal.     Escape  of  fertilized  ovum  into  peri- 
toneal cavity,  where  it  attaches  itself  to  the  intestine. 

(2)  Complete.     The  sac  comes  away  intact. 

(3)  Criminal.     Procured    artificially    without    being 
necessary   from    the   legal    standpoint   of   the   patient's 
health. 

(4)  Epidemic.     Arising  from  the  presence  of  conta- 
gious disease. 


166  OPERATING    ROOM 

(5)  Habitual.     Repeated,  due  to  syphilis  usually. 

(6)  Incomplete.     When  the  membrane  or  placenta  is 
retained. 

(7)  Inevitable.      When  the  sac  has  ruptured  and  the 
fetus  is  about  to  appear. 

(8)  Septic.     When     the     patient     becomes     infected 
through  the  introduction  of  bacteria  or  the  decay  of  re- 
tained tissue. 

(9)  Spontaneous.     Not  induced  by  artificial  means. 

(10)  Therapeutic.     Induced  to  save  the  mother's  life. 

(11)  Threatened.      Appearance    of    symptoms    which 
are  checked  by  putting  the  patient  to  bed  and  giving  her 
opiates.     This  usually  can  check  an  honest  miscarriage  in 
the  early  symptoms. 

Abscess.  A  localized  collection  of  pus  surrounded  by 
a  wall  of  leukocytes. 

Cold  Abscess.  Tuberculous,  usually  about  a  bone, 
joint,  or  gland — slight  pain,  no  acute  inflammation,  very 
slow. 

Psoas  Abscess.  Both  cold  and  psoas  are  misnomers, 
general^  low  Pott's  disease;  pus  from  the  spine  runs  along 
the  psoas  muscle  pointing  beneath  Poupart's  ligament. 
The  psoas  muscle  runs  from  the  lumbar  vertebrae  to  the 
lesser  trochanter  of  the  femur.  Poupart's  ligament  runs 
from  the  anterior  superior  spinous  process  of  the  ilium  to 
the  symphysis. 

Adenoma.  May  become  malignant,  as  sarcoma;  many 
are  benign,  but  some  are  most  malignant — an  epithelial 
tumor. 

Amenorrhea.     Abnormal  absence  of  menstruation. 

Aneurysm.  A  circumscribed  dilation  of  the  walls  of 
an  artery. 

Angioma.     A  tumor  formed  of  blood-vessels — benign. 

Anomaly.  An  abnormal  thing  or  occurrence,  a  marked 
departure  from  the  normal. 

Anteflexion.  A  bending  forward  or  doubling  on  itself 
forward. 

Antrum.     A  cavity  or  hollow  space  in  a  bone,  as  in 


TEEMS    USED    IN    SURGICAL    DIAGNOSIS  167 

the  mastoid,  often  infected;  antrum  of  Highmore  in  the 
superior  maxillary. 

Appendicostomy.  Opening  the  vermiform  appendix  at 
the  tip  and  irrigating  the  colon  downward  for  the  purpose 
of  eliminating  the  germs  which  make  that  their  abode. 

Appendix  (vermiform).  Small  blind  gut  hanging  from 
the  cecum. 

Ascites.  Obstruction  of  portal  circulation  in  chronic 
heart  and  kidney  diseases  causing  a  collection  of  fluid  in 
the  peritoneal  cavity.  To  let  off  this  transudate  we  "tap" 
or  do  a  "paracentesis"  with  a  trocar,  which  passes  through 
without  infecting  the  peritoneum,  with  aseptic  precau- 
tions. 

Asphyxia.     Suffocation;  lungs  deprived  of  oxygen. 

Atheroma.  A  sebaceous  cyst  containing  cheesy  mate- 
rial. 

Atresia.     Lack  of  normal  opening;  e.  g.,  to  the  vagina. 

Atrophy.  Diminution  in  the  size  of  a  tissue,  organ,  or 
part. 

Atypic.     Not  resembling  its  type;  irregular,  freakish. 

B 

Bartholin's  glands.  Vulvo vaginal  glands  whose  tiny 
openings  appear  about  at  the  center  of  the  inner  surface 
of  the  labia  minora,  a  seat  of  venereal  infection. 

Benign,  Benignant.     Not  endangering  health  or  life. 

Bile-duct.  The  haunt  of  the  Bacillus  coli  communis, 
the  typhoid  germ,  etc. 

Boil.  A  furuncle;  a  localized  inflammation  of  the  skin 
and  subcutaneous  tissues  with  formation  of  pus. 

Bone-grafting.  A  new  field  in  surgery,  dating  from 
about  1911,  where  a  healthy  bone  is  planted  to  splint  and 
support  or  take  the  place  of  an  unhealthy  one,  the  callus 
thrown  out  by  the  irritated  bone  forming  union;  e.  g., 
the  tibia  to  the  spine. 

Bubo.  Suppurative  inflammation  of  a  lymph-node, 
usually  in  the  groin  and  usually  venereal. 


168  OPERATING   ROOM 


Cachexia.  Depraved  condition  of  general  nutrition 
due  to  syphilis,  tuberculosis,  or  carcinoma;  weak,  tough, 
yellow,  muddy  skin,  and  emaciation. 

Calculus.  Stones  in  the  ureter,  kidney,  gall-duct,  or 
bladder,  sometimes  causing  occlusion  of  the  ureters  and 
consisting  of  uric  acid,  oxalate  of  lime,  phosphates  or 
cystin — a  stone-like  concretion  inciting  pyelonephritis — 
when  in  the  gall-ducts,  of  bile  pigment.  See  Gall-stones. 

Capsule.  A  receptacle  or  bag;  covering  of  certain 
organs;  e.  g.,  the  Tddney,  the  liver,  some  cysts,  and  parts 
of  the  eye. 

Carbuncle.  Hard,  circumscribed,  deep-seated,  painful, 
suppurative  inflammation  of  subcutaneous  tissue,  larger 
than  a  boil,  with  a  flat  top  and  several  points  of  suppura- 
tion. 

Carcinoma.  Malignant  epithelial  tumor  prone  to  local 
extension  through  the  lymph-spaces.  It  may  appear  at 
any  age  and  may  have  inflammation,  ulceration,  and 
hemorrhage.  It  is  more  frequently  found  in  some  parts 
of  the  world  than  in  others.  The  age  limit  is  said  to  be 
lower  now  only  because  patients  are  handing  themselves  up 
sooner  to  physicians  and  the  complex  life  of  this  time 
ages  people  faster.  Epithelioma  occurs  in  skin  where 
it  joins  the  mucous  membrane  on  the  lips,  eyelids,  labia, 
mouth,  esophagus,  vagina,  or  cervix.  It  may  not  recur 
if  thoroughly  removed,  and  is  the  least  malignant  of  the 
carcinomata.  Cylindric-celled  carcinoma  occurs  in  the 
stomach,  intestine,  and  uterus.  Carcinoma  simplex 
occurs  in  the  mammae,  stomach,  liver,  thyroid,  salivary 
and  prostate  glands,  in  the  pancreas,  testicle,  ovary, 
and  kidney.  Some  of  these  are  the  most  malignant. 
There  has  been  no  serum  or  toxin  yet  discovered  as  a 
cure,  but  early  recognition  and  early  radical  operation 
save  many  lives. 

Caries.  Death  of  bone;  similar  to  ulceration  of  soft 
tissues. 


TERMS    USED    IN    SURGICAL    DIAGNOSIS  169 

Caruncle.  Small,  fleshy  growth,  frequent  in  women, 
in  the  meatus  urinarius. 

Chalazion.  A  tumor  of  the  eyelid  from  retained  secre- 
tion of  the  meibomian  glands. 

Cholecystitis.     Inflammation  of  the  gall-bladder. 

Cholelithiasis.  Presence  of  stones  in  the  gall-bladder 
or  gall-duct  composed  of  bile  pigment,  that  is,  choles- 
terin  and  certain  salts.  By  lying  together  they  become 
facetted,  and  may  exist  in  as  large  numbers  as  7800.- 

Cholesteatoma.  Cells  packed  with  cheesy  matter, 
benign  tumors  in  the  dura  behind  the  ear;  found  in 
mastoid  operations. 

Chondroma.  Benign  tumor  of  the  covering  of  carti- 
lage, but  it  may  extend  into  the  lungs  or  heart. 

Cicatrix.  A  scar;  connective  tissue  replacing  a  local 
loss  of  substance,  the  new  being  red  or  purple,  the  old 
white,  hard,  shrivelled,  and  shiny. 

Circumcision.  Removal  of  foreskin  or  prepuce  for 
cleanliness  and  prevention  of  self-abuse. 

Cirrhosis.  Chronic  inflammation  of  an  organ  and  over- 
growth of  connective  tissue. 

Clitoris.  A  very  small  organ  in  the  female  in  front  of 
the  pubic  joint,  somewhat  resembling  the  penis  in  the 
male,  and  extirpated  to  check  self -abuse. 

Colic.  Biliary.  Passage  of  gall-stones  through  the 
gall-duct  into  the  duodenum. 

Renal.     Pain  caused  by  stone  in  the  ureter. 

Appendiceal.  Pain  and  rigidity  of  spasms  due  to  in- 
flammation. 

Intestinal.  Severe  griping  pain  in  the  bowels  due  to 
spasm  of  the  intestinal  walls. 

Comedo  (sing.),  Comedones  (pi.).  Disorder  of  the  se- 
baceous glands;  in  the  young,  yellowish  elevations  with 
black  points  in  the  center  associated  with  acne. 

Condyloma.  A  wart-like  growth  or  tumor  near  the 
anus. 

Congenital.     Existing  at  and  since  birth. 

Convergent.     Coming  together,  as  in  squint. 


170  OPERATING    ROOM 

Cornu  (sing.),  Cornua — horns  (pi.)-  The  projecting 
upper  corners  of  the  uterus  into  which  open  the  Fal- 
lopian tubes. 

Cul  de  sac  of  Douglas.  A  pouch  between  the  front 
wall  of  the  rectum  and  the  back  wall  of  the  uterus  made 
by  the  peritoneum. 

Curettage.  Curetment — scraping  out  the  uterus.  It 
is  essential  for  the  honor  of  the  hospital  to  have  a  true 
history. 

Cyst.  A  cavity  containing  fluid  and  surrounded  by  a 
capsule. 

Cystocele.  Hernia  of  the  bladder.  The  back  wall  of 
the  bladder  drops  down,  pushing  out  the  front  wall  of  the 
vagina,  the  weight  of  urine  increases  this,  and  finally  may 
pull  down  the  cervix  and  the  uterus. 


D 

Decapsulation.  Taking  off  the  capsule  of  a  diseased 
organ  to  establish  new  circulation  and  reduce  inflamma- 
tion, as  of  the  kidney,  for  nephritis  or  bichlorid  poisoning. 

Dermoid  cyst.  A  sac  containing  hair,  teeth,  nails, 
and  other  forms  of  epithelial  tissue. 

Detritus.     Waste  matter  from  disorganization. 

Dilation.     As  correct  as  dilatation — act  of  stretching. 

Distal.     Farther  away  from  the  point  mentioned. 

Divergent.     Going  apart,  as  in  squint. 

Diverticulum  (of  bladder  or  esophagus).  A  pouch  or 
sac  springing  from  a  weakness  in  the  wall  of  a  main 
structure,  causing  the  contents  to  stop  there  which  should 
pass  on;  symptom  of  diverticulum  of  esophagus  in  an  adult, 
regurgitation  of  food  just  as  sweet  as  when  swallowed. 

Dorsum.     The  back  of  the  hand,  foot,  tongue,  etc. 

Dura  mater.  Membrane  covering  the  concave  surface 
of  the  skull,  "exposed"  in  ear  operations  under  strict 
aseptic  precautions,  "going  in"  from  outside,  or  the  outer- 
most of  the  three  coverings  of  the  brain. 

Dysmenorrhea.     Painful  menstruation. 


TERMS    USED    IN    SURGICAL   DIAGNOSIS  171 


Ecchymosis. — Large  diffuse  accumulation  of  blood  in 
the  interstices  of  the  tissues. 

Ectropion.  A  disease  of  the  eyelid  turning  it  inside 
out. 

Effusion.  A  pouring  out  of  blood  or  serum  into  serous 
cavities  (pleura,  peritoneum,  pericardium). 

Embolism.  Blocking  of  a  blood-vessel,  especially  an 
artery,  by  foreign  matter. 

Embryonic.  Pertaining  to  the  embryo,  or  fertilized 
ovum  of  an  animal. 

Encapsulated.  Surrounded  by  a  capsule,  as  a  bullet 
or  any  other  foreign  body. 

Endometritis.  Inflammation  of  the  lining  of  the  uterus, 
with  swelling,  congestion,  and  even  hemorrhages. 

Endothelioma.     A  sarcoma  in  the  lymphatics. 

Endothelium.  Lining  of  blood-  and  lymph-vessels 
and  of  serous  and  synovial  cavities. 

Entropion.  A  disease  of  the  eyelid  turning  it  outside 
in,  so  that  the  lashes  constantly  scratch  the  eyeball. 

Epididymitis.  (Note  spelling.)  Inflammation  of  epi- 
didymis,  small  organ  lying  above  the  testes. 

Epispadias.  Opening  of  urethra,  not  at  the  end,  but 
on  the  upper  side  of  the  penis,  due  to  arrested  develop- 
ment. 

Epithelioma.  Carcinoma  of  the  skin  and  mucous  mem- 
branes. 

Exostosis.  Bony  tumor;  an  abnormal  projection  of 
bone. 

Extra-uterine  pregnancy.  Gestation  outside  the  uterus, 
in  the  tube,  fimbrise,  peritoneum,  or  on  the  intestines. 

Extravasation.  Passing  of  fluid  outside  of  a  cavity 
in  which  it  normally  ought  to  stay  (of  blood  or  lymph). 

Exudate.  The  material  that  has  passed  through  the 
walls  of  vessels  into  the  adjacent  tissues  (said  of  serum  or 
pus). 


172  OPERATING   ROOM 


Felon.  Inflammation  of  flexor  tendons  and  tendinous 
sheaths  of  the  finger.  See  Paronychia,  Whitlow. 

Fenestrated.  Having  a  window  or  opening,  as  in  a 
rubber  drainage-tube,  a  pair  of  obstetric  forceps,  or  a 
plaster  cast  over  a  sinus. 

Fibrin.  Coagulating  material  in  blood;  small  bunches 
of  twigs  are  used  to  whip  clots  to  separate  the  fibrin  in 
looking  for  fetal  or  placental  tissue. 

Fibroma.  A  tumor,  benign  at  first,  in  skin  and  sub- 
cutaneous tissue  may  become  serious  through  pressure, 
ulceration,  etc. 

Fissure.  A  groove  or  cleft  (normal)  in  the  skull, 
brain,  liver,  cord,  etc.;  an  abnormal  fissure  occurs  at  the 
junction  of  skin  and  mucous  membrane,  as  the  lips  or  the 
anus. 

Fistula  (sing.),  Fistulae  (pi.),  Fistulous  (adj.).  A  narrow, 
winding,  irregular  canal  in  the  soft  tissues  left  by  in- 
complete healing  of  an  abscess  or  wound  with  fluid  con- 
tents; must  be  entirely  laid  open  and  the  edges  bevelled 
off  so  as  not  to  approach  again  (usually  rectal). 

Flap.  A  piece  of  soft  tissue  cut  on  three  sides  of  a 
square  and  laid  back  to  cover  a  scar,  or  to  bring  forward 
after  an  amputation  to  cover  a  bone  end. 

Floating.  Free  to  move  around;  abnormal,  as  a  kid- 
ney, which  has  no  ligaments  at  all  to  hold  it  up,  merely 
fat. 

Fossa.     A  depression  or  pit. 

Frenum.  A  rib  or  fold  of  skin  or  mucous  membrane 
that  limits  the  movement  of  any  organ.  Under  a  new- 
born infant's  tongue  an  abnormal  frenum  should  be 
promptly  snipped  or  it  cannot  nurse  and  will  be  tongue- 
tied. 

Frontal  sinus.  Hollow  air-spaces  in  the  frontal  bone; 
a  seat  of  infection  that  becomes  fatal  at  times  through 
the  easy  way  of  reaching  the  brain;  operated  through  the 
nose. 


TERMS    USED    IN    SURGICAL    DIAGNOSIS  173 

Furuncle.    A  boil. 

Furunculosis.  The  constant  formation  of  a  succession 
of  boils. 

G 

Gangrene.  Death  of  a  considerable  mass  of  tissue. 
When  it  is  mummified,  dry  and  hard,  brown  or  black 
it  is  classified  as  dry  gangrene;  when  discolored  and 
putrefying,  moist  gangrene.  It  proceeds  from  wounds, 
diabetes,  and  other  causes.  It  is  not  a  cause  for  panic 
now,  as  formerly,  in  hospital  wards. 

Glaucoma.  Disease  of  the  eye,  with  heightened  ten- 
sion, hardness  of  globe,  lessening  of  visual  power,  restric- 
tion in  field  of  vision,  dreadful  headache,  etc. ;  relieved  by 
iridectomy. 

Glioma.  Tumor  of  neuroglia  cells  in  the  brain,  cord, 
retina,  nerves,  and  suprarenals;  benign. 

Granulations.  Formation  of  new  vascular  but  nerve- 
less tissue  in  repair  of  wounds. 

Gumma.  Third  stage  of  syphilis  in  the  brain.  Should 
take  precautions  against  contagion.  .It  is  a  tumor  with  a 
gummy  appearance,  consisting  of  granulations  and  show- 
ing peculiar  degeneration. 

H 

Hematocele.     Blood  extravasated  into  a  closed  cavity. 

Hematoma.  Collection  of  blood  in  a  tumor-like  mass 
on  a  newborn  infant's  "caput,"  be  it  the  head  or  but- 
tocks. 

Hemophilia.  All  words  with  the  prefix  hem  (for  blood) 
as  their  root  should  be  spelled  hem  uniformly.  Hemor- 
rhagic  diathesis,  condition  of  being  a  bleeder.  Important 
question  to  ask  in  taking  a  history.  When  circumcising  a 
newborn  infant  he  proved  a  bleeder,  and  after  all  other 
means  failed,  a  large  number  of  the  tiniest  clamps  ever 
made,  covering  the  whole  wound,  saved  his  life. 

Hermaphrodite.  A  human  being  whose  organs  are  so 
malformed  as  to  partake  of  the  nature  of  both  sexes. 


174  OPERATING    ROOM 

Hydatid  mole  (hydatidiform) .  Hypertrophy  of  the 
villi  of  the  chorion,  beginning  as  a  fibrous  mole;  then  its 
mucous  membrane  degenerates,  then  a  hydatid  mole. 

Hydrocele.  Accumulation  of  fluid  (serous)  in  the 
tunica  vaginalis  about  the  testicle  or  the  spermatic  cord. 

Hydrocephalus  (the  noun,  note  ending  us).  A  head 
containing  a  collection  of  fluid  in  the  cerebral  ventricles, 
with  steady  increase  in  size. 

Hydrosalpinx.  Fallopian  tube  dilated  with  water  into 
the  shape  of  a  cyst. 

Hymen.  A  fold  of  mucous  membrane  partially  closing 
the  virginal  vaginal  opening. 

Hypospadias.  The  male  urethral  opening  into  a  cleft 
on  the  under  side  (arrested  development). 

Hypostasis.  The  settling  of  blood  in  the  dependent 
or  low-lying  parts  of  the  body. 


I 

Ileus  (volvulus).  A  twisting  of  the  bowel  so  as  to»  ob- 
struct the  passage  of  air,  feces,  or  fluid;  usually  fatal. 

Impaction.  A  mass  of  fecal  matter  or  calculi  solidly 
packed;  stones  in  the  cystic  duct  cause  dilation  of  the 
gall-bladder;  very  large  stones  sometimes  cause  occlu- 
sion of  the  gut. 

Imperforate.  Without  a  normal  opening,  as  of  the 
anus  (a  hole  from  the  rectum  often  leads  to  the  vagina 
instead). 

Incarcerated.  Walled  in  and  bound  around,  as  a 
hernia  in  a  sac. 

Infarction.  A  circumscribed  portion  of  tissue  com- 
pletely infiltrated  with  blood. 

Infiltration.  The  entrance  into  the  tissues  (1)  of  some 
abnormal  substance  or  (2)  of  some  normal  substance 
(as  blood)  in  too  great  a  quantity. 

Inflammation.  Heat,  swelling,  redness,  pain,  and  im- 
pairment of  function;  a  rush  of  leukocytes  to  fight  the 
invasion  of  bacteria. 


TERMS    USED    IN    SURGICAL    DIAGNOSIS  175 

In  situ.     In  the  natural  position. 

In  statu  quo.     In  the  natural  condition. 

Intercostal  spaces.  The  muscular  areas  between  the 
ribs,  numbered. 

Intussusception.  Slipping  of  one  part  of  the  intestine 
into  the  part  beyond;  telescoping  of  the  bowel  on  itself, 
as  the  ileum  into  the  colon. 

Invagination.  Act  of  insheathing  or  being  run  into  a 
sheath,  as  inverting  the  raw  end  of  the  appendix  stump 
inside  itself. 


Keloid.  An  overgrowth  of  tissue  standing  out  like  a 
very  full  frill,  usually  in  any  old  scar,  and  very  common 
in  the  negro  race. 

Kidneys.  Subject  to  inflammation,  have  no  support- 
ing ligaments,  malformations  quite  common,  as  two  in  one 
or  one  missing,  or  one  with  two  ureters,  have  tumors  of 
various  kinds;  the  healthy  one  should  not  be  removed  by 
mistake,  this  being  the  result  of  carelessness  in  marking 
specimens  obtained  after  catheterizing  the  ureters. 


Laceration.  A  tear,  especially  of  the  cervix  or  peri- 
neum in  childbirth;  repair  is  imperative. 

Lamina.     Plates  or  layers  applied  to  vertebrae. 

Laminectomy.  Removal  of  the  posterior  arches  of  the 
vertebrae. 

Lateral.  Belonging  to  the  side;  in  a  sideways  direc- 
tion. 

Leiomyoma.     Benign  tumor  of  involuntary  muscle. 

Lesion.  An  injury,  a  wound,  or  any  diseased  morbid 
condition  in  an  organ. 

Leukocytes.    White  corpuscles. 

Leukorrhea.  Whitish  mucopurulent  discharge  from 
the  female  genital  canal. 

Lipoma.     Benign,  fatty  tumor. 


176  OPERATING   ROOM 

Lobe.  A  rounded  part  of  an  organ,  separated  from 
the  others  by  fissures  or  clefts. 

Longitudinal.  Lengthwise;  in  the  longest  direction  of 
the  body. 

Lymphangioma.  Benign  but  may  rupture;  a  tumor 
made  of  lymphatic  vessels. 

M 

Malformation.  An  abnormal  development  or  forma- 
tion of  a  part  of  the  body. 

Malignant.  Applied  to  tumors;  harmful,  fatal.  Known 
if  (1)  they  spread  by  metastases;  (2)  they  invade  adja- 
cent material  by  eccentric  or  peripheral  growth;  (3)  they 
tend  to  recur;  (4)  they  interfere  with  the  nutrition  and 
general  well-being  of  the  body,  inducing  cachexia, 

Malposition.  An  abnormal  position  of  any  part  or 
organ. 

Mastitis.  In  infants  streptococcic  or  staphylococcic 
infection.  Use  no  pressure,  no  massage.  Inflammation  of 
the  breasts  found  in  nursing  mothers. 

Mastoiditis.  Inflammation  of  mastoid  cells  behind  the 
ear. 

Do  not  confuse  these  two  terms. 

Median  line.  A  line  in  the  center  of  the  body  from  the 
umbilicus  to  the  symphysis  pubis;  imaginary. 

Menorrhagia.     Excessive  menstrual  flow. 

Metastasis  (sing.),  Metastases  (pi.).  Transfer  of  dis- 
eased particles  by  the  blood  or  lymph  from  the  primary 
bed  to  a  distant  one. 

Metrorrhagia.  Uterine  hemorrhage;  not  connected 
with  the  menses  or  childbirth. 

Microcephalon.     An  abnormally  small  head. 

Milium.  Small,  pearly,  non-inflammatory  elevations 
on  the  skin  due  to  plugging  of  sebaceous  glands. 

Mole.     Birthmark;  a  pigmented  nevus. 

Mouse-tooth.  Forceps  with  sharp  teeth  like  a  mouse's. 
Do  not  be  guilty  of  saying  "mouth-tooth." 


TERMS    USED    IN    SURGICAL    DIAGNOSIS  177 

Multilocular.     Having  many  cysts  or  "eyes" — middle 

(1)  put  in  for  ease  in  pronouncing. 

Multiple.     Affecting  many  parts  at  the  same  time. 

Myoma.  Benign  muscular  tumor,  frequent  in  the 
uterus. 

Myxoma.  A  benign  growth  in  connective  tissue,  but 
may  recur;  containing  mucin,  like  Wharton's  jelly  in  the 
umbilical  cord. 

N 

Naevus  or  Nevus.  Vascular  birthmark;  "strawberry 
mark";  an  angioma  full  of  blood-vessels,  benign  and  con- 
genital, corrected  by  skin-grafting. 

Necrosis.  Death  of  a  limited  portion  of  tissue  due  to 
insufficient  nutrition  by  (1)  cutting  off  the  blood-supply; 

(2)  bacteria;  (3)  mechanical  injury. 

Neuroglia.  Has  its  origin  in  nervous  tissue,  but  takes 
on  the  duties  of  connective  tissue. 

Neuroma.     Benign  tumor;  new  formed  nerve  tissue. 

Node.  A  knob,  swelling,  or  protuberance;  the  normal 
shape  of  many  lymph-vessels. 

Nodule.     A  little  node. 

Noma.  Not  surgical.  An  ulcer  in  the  cheek  rapidly 
spreading  down  the  alimentary  canal. 

o 

Obliteration.     Removal  or  disappearance  of  a  part. 

Obstruction.     Blocking  of  the  blood  or  the  bowel. 

Occlusion.  Closing  or  blocking  off,  as  of  the  Fallopian 
tubes,  inducing  sterility;  or  of  the  gall-duct  with  gall- 
stones. 

(Edema  or  Edema.     Infiltration  of  serum  into  a  part. 

Omentum.  Useful  for  absorption  and  its  fat  supply; 
a  fold  of  peritoneum  hanging  down  like  an  apron  in  front 
of  the  intestines. 

Obphoritis.  Note  spelling,  marking,  and  pronuncia- 
tion, not  like  oo  in  foot,  but  like  oa  in  oasis.  An  inflam- 
12 


178  OPERATING    ROOM 

mation  of  the  ovary  after  the  puerperium,  or  it  may  be  a 
primary  affection. 

Orchitis.     Inflammation  of  the  testicle. 

Organized  clot.  Found  in  curettings;  blood  converted 
into  something  looking  like  an  organ  or  other  living 
tissue.  When  curettings  are  examined  they  should  be 
whipped  with  a  bunch  of  twigs  to  separate  the  fibrin  so 
as  not  to  miss  a  tiny  fetus. 

Osteitis  or  Ostitis.     Inflammation  of  bone. 

Osteoclast.  An  instrument  for  breaking  bones  (bow- 
legs). 

Osteoma.  When  alone,  benign;  new  formed  bones 
found  in  the  soft  parts,  such  as  the  pleura  or  the  dia- 
phragm, but  often  combined  with  sarcoma. 

Osteomalacia.  A  disease  mostly  of  pregnant  women; 
by  the  loss  of  inorganic  salts  bone  which  was  hard  and 
fully  formed  becomes  softened  and  twisted,  sometimes 
necessitating  cesarean  section. 

Osteomyelitis.     Inflammation  of  the  marrow  of  bone. 

Osteoplasty.  Operation  for  bow-legs  or  knock-knees, 
for  the  cosmetic  effect. 

Osteosarcoma.     A  sarcoma  containing  bone. 

Otitis  media.  Inflammation  of  the  middle  ear.  Diag- 
nostic : 

0.  m.  c.  c.     Otitis  media  chronica  catarrhalis. 

0.  m.  c.  a.     Otitis  media  catarrhalis  acuta. 

0.  m.  p.  c.     Otitis  media  purulens  chronica. 

0.  m.  p.  a.     Otitis  media  purulens  acuta. 

Ovary  transplantation.  Taking  a  healthy  ovary  from 
one  woman  and  sewing  it  into  place  in  the  body  of  an- 
other woman  (1)  to  correct  sterility;  (2)  to  keep  the  val- 
uable ovarian  secretions  acting  to  prevent  neurasthenia 
or  masculinity. 


Papillomata.    Warty  growths,  fibromata,  of  the  skin;  a 
papillary  outgrowth  covered  with  epithelium. 
Paracentesis.    Puncture  into  a  body  cavity  (ear,  ab- 


TERMS    USED    IN    SURGICAL    DIAGNOSIS  179 

domen,  bladder,  thorax,  cornea);  a  "paracentesis  knife" 
for  ear  work  has  a  very  small  two-edged  blade,  so  small 
that  it  can  pass  through  a  small  ear  speculum. 

Parenchyma.  The  essential  or  working  part  of  an  or- 
gan (e.  g.,  the  kidney) ;  the  body  without  the  covering. 

Paresis.  Some,  but  not  complete,  loss  of  muscular 
power  (intestinal). 

Patent.     Open  or  exposed,  as  a  valve. 

Patulous.     Expanded  or  open. 

Pedicle.     The  stem  or  stalk  of  a  tumor  or  cyst. 

Pediculated  cyst.  Growing  from  the  broad  ligament 
and  having  a  pedicle. 

Perichondrium.    The  fibrous  coat  of  cartilage. 

Perineum.  The  floor  of  the  pelvis  from  pubes  to 
coccyx  (adj.,  perineal). 

Peritoneum.  Serous  sac  lining  the  whole  abdominal 
cavity  and  containing  the  viscera  (adj.,  peritoneal). 

Peroneal.  Pertaining  to  the  fibula,  or  small  bone  of 
the  leg. 

Do  not  confuse  these  three  terms. 

Periosteum.  Fibrous  covering  of  bone — not  to  be 
destroyed. 

Periostitis  or  Periosteitis.  Inflammation  of  the  perios- 
teum. 

Petechiae.  Very  minute  hemorrhages  into  the  skin; 
sometimes  seen  in  the  newborn  and  others  (adj.,  petechial). 

Phagedena.  A  rapidly  spreading  destructive  ulcer  of 
the  soft  parts. 

Phlegmon.  Inflammation  with  spreading  of  purulent 
exudate  within  the  tissues. 

Pia  mater.  Membrane  covering  the  convex  surface  of 
the  brain,  the  middle  one  of  the  three  meninges. 

Pneumothorax.  Air  in  the  pleural  cavity — (1)  injury 
to  the  chest  wall,  going  into  it  from  without,  (2)  or  from 
the  lung  channel,  as  if  coming  out,  (3)  or  by  ulceration  or 
suppuration  in  adjacent  organs,  intestines,  esophagus,  etc. 

Polypus.  A  tumor  with  a  pedicle,  as  a  growth  in  the 
ear,  nose,  bladder,  uterus,  urethra,  or  rectum. 


180  OPERATING   BOOM 

Prepuce.  Foreskin;  fold  of  skin  lined  with  mucous 
membrane  under  which  dirt  accumulates. 

Primary  union.  The  clean  joining  of  two  edges  of  a 
wound,  as  in  a  herniotomy.  One  should  always  be  very 
ambitious  to  have  primary  union  of  severed  tendons;  for 
instance,  where  function  would  be  seriously  impaired. 
Divided  nerve  ends  cannot  have  union. 

Procidentia.     Prolapse,  a  falling  down  (of  the  uterus). 

Prolapse.     A  falling  down  (as  of  the  rectum). 

Prostatitis.  Inflammation  of  the  prostate  gland  from 
old  age,  injuries,  or  gonorrhea. 

Proximal.  Of  the  two  ends  of  an  object;  the  nearer  to 
a  chosen  point. 

Psoas.     Muscle  of  the  loin  and  pelvis. 

Ptosis.  Drooping  of  the  eyelid  with  loss  of  nerve 
power;  dropping  of  the  intestine  or  stomach. 

Purulent.     Not  pussy.     Containing  pus. 

Pus.  Liquid  formed  of  dead  and  living  bacteria  and 
leukocytes;  also  the  fluids  they  have  thrown  off  in  their 
conflict  in  a  part  that  has  been  inflamed. 

Pustule.  A  small  elevation  on  the  skin  containing 
pus. 

Pyaemia  or  Pyemia.  Following  septicemia  fresh  sup- 
purating foci  are  developed  all  over  the  body;  metastatic 
abscesses. 

Pyelitis.  Inflammation  of  the  pelvis  of  the  kidney 
(the  main  part). 

Pyosalpinx.     A  tube  distended  with  pus. 


Rachitis.  Malformation  of  chest  and  bones  due  to  im- 
proper nourishment.  When  placing  a  rachitic  patient  on 
the  operating-table  one  is  surprised  to  find  such  irregular- 
ities in  the  bones  of  the  legs  that  they  can  hardly  fit  into 
the  stirrups. 

Ranula.  A  small  tumor,  very  troublesome,  in  Whar- 
ton's  duct  obstructing  the  salivary  fluid. 


TERMS    USED    IN    SURGICAL   DIAGNOSIS  181 

Rectocele.  A  sac  of  relaxed  vaginal  wall,  posterior, 
pushed  down  by  the  relaxed  front  wall  of  the  rectum. 

Rectovaginal  fistula.  Usually  congenital;  unclean; 
accompanying  imperforate  anus. 

Renal.     Pertaining  to  the  kidneys. 

Resolution.  Return  of  a  part  to  normal  after  some  dis- 
eased condition,  as  of  the  lung  in  pneumonia. 

Retained  (placenta).  Left  in  when  it  should  normally 
come  out,  also  as  of  a  soapsuds  enema. 

Retroflexion.     Bent  backward  on  itself  (uterus). 

Retroversion.  Falling  back  as  a  whole  without  doub- 
ling on  itself. 

Rupture.  A  bursting  of  a  sac  or  blood-vessel  (also  of 
an  inflamed  appendix);  the  lay  word  for  hernia;  incorrect 
because  there  is  only  displacement. 


Sac.  A  bag  or  the  bulging  cover  of  a  cyst  or  tumor; 
in  hernia,  the  bag  growing  around  the  dropped  loop  of 
intestine;  a  natural  cavity. 

Sarcoma.  Travels  by  way  of  the  blood-vessels,  to  dis- 
tinguish it  commonly  from  carcinoma.  It  is  malignant 
and  found  in  early  life.  It  occurs  in  the  skin,  subcuta- 
neous tissue,  subserous  connective  tissue,  fasciae,  perios- 
teum, and  choroid  of  the  eye  most  frequently.  It  is  also 
found  in  the  brain,  cord,  lymph-nodes,  uterus,  ovary, 
bladder,  and  kidney,  from  which  last  it  can  be  projected 
into  the  lungs  and  heart. 

Sebaceous.     Pertaining  to  the  oil-glands  of  the  skin. 

Septicaemia  or  Septicemia.  A  condition  in  which  bac- 
teria and  their  toxins  are  distributed  all  through  the  body 
by  the  blood  and  the  lymph. 

Septum.  A  partition,  may  be  deviated,  in  the  nose; 
sometimes  a  double  vagina  is  found  with  a  septum  be- 
tween the  two  halves. 

Seropurulent.  Having  partly  the  nature  of  both  serum 
and  pus. 


182  OPERATING   ROOM 

Serous.     Pertaining  to  or  resembling  serum. 

Serum.  Clear  yellowish  fluid  separated  from  the  blood 
after  the  coagulated  fibrin  is  removed. 

Severed.     Cut  in  two,  as  a  tendon  or  a  nerve. 

Sinus.  (1)  A  large  channel  containing  blood,  as  the 
lateral  sinus,  disturbed  in  some  ear  operations;  (2)  a 
cavity  within  a  bone  (frontal);  (3)  a  worm-like  opening 
from  tissues  for  drainage  in  an  old  wound;  an  effort  of 
nature  to  show  that  some  foreign  body  has  been  left  in, 
as  silkworm-gut  instead  of  chromic  gut. 

Slough.  Death  and  throwing  off  of  tissue,  as  after  a 
deep  burn. 

Spasm.     Sudden  muscular  contraction  with  pain. 

Stenosis.  Constriction  or  narrowing  of  a  passage  so 
that  what  should  normally  pass  through  cannot,  as  aortic 
stenosis  or  stenosis  of  the  cervix. 

Strangulated.  Compressed  and  twisted  so  as  to  cut  off 
the  blood-supply,  as  in  a  hernia;  black  and  gangrenous. 

Strabismus.     Squint.     Do  not  say  "strabismuth" ! 

Stricture.  Narrowing  of  a  canal  from  inflammation  of 
its  inner  walls;  frequently  from  infection,  not  always. 

Subinvolution.  Imperfect  contraction  of  the  uterus 
after  childbirth. 

Supernumerary.  Extra,  as  of  a  thumb  or  any  other 
digit  sprouting  out  from  the  base  of  the  normal  one. 

Synovitis.  Inflammation  of  the  synovial  membrane; 
may  be  suppurative. 


Teratomata.  Congenital  growths  containing  all  forms 
of  connective  tissue  (cartilage,  hair,  skin,  teeth,  nails, 
bone,  glands),  and  found  in  the  end  of  the  spine,  head, 
neck,  glands,  and  generative  organs,  probably  part  of 
another  fetus. 

Thickening.     A  swelling  due  to  old  inflammation. 

Thrombosis.     Organized  blood-clot  blocking  a  vein. 

Tight  lacing.  Cause  of  displacement  of  kidneys,  pan- 
creas, liver,  and  uterus. 


TERMS    USED    IN    SURGICAL    DIAGNOSIS  183 

Torsion.  Twisting,  as  a  big  tumor  on  its  pedicle,  be- 
coming a  strangulation. 

Transplantation.  Applying  to  one  part  the  tissues 
taken  (1)  from  the  same  body;  (2)  or  from  the  same  part 
of  another  body  like  it. 

Transposition.  Wrong  position  from  birth,  as  liver  on 
the  left,  heart  on  the  right,  etc. 

Transudation.  Passing  of  fluid  through  a  membrane, 
as  blood  through  its  vessel  walls. 

Trauma.     Condition  of  being  wounded. 

Tubal  pregnancy.  Growth  of  fertilized  ovum  in  the 
tube. 

Tubercle.  A  specific  lesion  produced  by  the  germ  of 
tuberculosis  (the  tubercle  bacillus);  a  nipple  or  nodule  of 
diseased  tissue  visible  to  the  naked  eye. 

Tuberculosis  of  the  joints  or  peritoneum  is  operable; 
opening  for  drainage  or  exposure  to  direct  sunlight. 

Tumors.  Circumscribed  new  growths  of  tissue — 
nodular,  tuberous,  fungoid,  polypoid,  papillary,  dendritic, 
or  lobulated.  Some  are  benign,  others  malignant. 


U 

Ulcer.  Gradual  death  of  the  tissue  of  the  skin  or 
mucous  membranes. 

Ulceration.  Necrosis  with  erosion  (wearing  off)  in- 
volving the  surface  of  the  skin,  mucous  or  serous  mem- 
brane, due  to  inflammation  or  cutting  off  of  nutrition. 

Urachus.  Remains  of  fetal  life  sometimes  found  in  the 
abdomen  during  an  operation  for  a  different  purpose;  a 
canal  about  6  cm.  long,  with  a  small  opening  into  the 
bladder  or  entirely  closed  at  that  place;  if  there  are  certain 
congenital  malformations  the  urine  may  flow  through 
the  urachus;  in  the  adult  a  slight  distention  visible  up  to 
the  navel  shows  that  the  urachus  was  never  obliterated. 


184  OPERATING   ROOM 


Varicocele.  Veins  of  the  spermatic  cord  dilated  and 
forming  twisted  masses. 

Varicosity.  A  swollen  vein,  knotted  and  tortuous, 
resembling  a  bunch  of  grapes. 

Vascular.     Having  many  blood-vessels. 

Vesicovaginal  fistula.  Requires  a  special  bed;  an  open- 
ing from  the  bladder  to  the  vagina  with  constant  dribbling 
of  urine;  very  common  after  childbirth,  due  to  pressure 
and  necrosis  before  the  invention  of  obstetric  forceps.  If 
a  patient's  bladder  is  full  the  surgeon  may  snip  it  acci- 
dentally, causing  a  vesicovaginal  fistula.  Sims  earned 
the  eternal  gratitude  of  his  time  by  repairing  it  com- 
pletely with  silver  wire. 

Vicarious.  Relating  to  an  habitual  discharge  of  blood 
in  an  abnormal  part  of  the  body,  but  never  in  the  vagina, 
as  a  substitute  for  menstruation. 

W 

Walled-off.  Shut  in  or  bounded  by  a  solid  body  of 
leukocytes  in  nature's  effort  to  check  the  invasion  of 
bacteria. 

Wen.     A  sebaceous  cyst. 

Whitlow.    Same  as  Felon. 


CHAPTER  XIV 


LIST   OF  INSTRUMENTS  FOR  CERTAIN 
OPERATIONS 


Head. — General  Work. 

Scalpels. 

Mouse-tooth  forceps. 

Anatomic  forceps. 

Artery  clamps. 

Scissors. 

Sharp  retractors. 

Periosteal  elevators. 

Trephines. 

Gigli  saw  with  its  handles 

(Figs.  21,  22). 
Bullet  searcher. 
Rongeurs. 


Fig.  21. — Gigli  saw. 


Sharp  curets. 

Mallet. 

Chisels. 

Gouges. 

Probes. 

Aspirating   needles   and 

syringe. 

Needle-holder  (Fig.  23). 
Bone-wax. 

Twisted  catgut  drain. 
Rubber  tissue  drain. 


Fig.  22.— Handles  for  Gigli 
saw  (in  pairs). 


Needles. — (1)  Small  round  body  and  very  fine  catgut 
for  the  meninges;  (2)  medium-sized  curved  Hagedorn  for 


185 


186  OPERATING    ROOM 

scalp  for  silkworm-gut  or  silk  (to  be  removed),  or  curved 
needle  with  cutting  edge. 

Accessories. — Lighting  of  the  room,  headlight,  dress- 
ings, towels,  laparotomy  sheet,  sand-bags;  sterilize  elec- 
trodes, cover  all  electric  appliances  near  the  wound  with 
sterile  gauze;  have  clippers,  a  safety  razor,  and  a  good 
common  razor;  put  a  bandage  around  the  brow  for  con- 
striction; starch  bandage  is  put  over  all  and  wet  to  set; 
the  hair  at  the  edge  of  the  shaved  area  is  plastered  down 
with  gauze  steeped  in  collodion. 

Notes. — The  head  nurse  should  make  a  drawing  of  the 
various  layers — hair,  scalp,  periosteum,  bone,  dura 
mater,  pia  mater,  arachnoid  membrane,  and  brain  tissue. 


Fig.  23.— Richter  needle-holder  (5£  to  8  inches). 

For  all  intracranial  work  keep  the  blood-pressure  apparatus 
on  hand. 

Mastoid. — This  list  provides  enough  for  the  assistant 
also: 

5  rongeurs  (McKernon,  Adams,  Pyle,  Janvier,  bulldog). 

1  mallet. 

3  chisels  (graded). 

3  gouges  (graded). 

4  spoon  curets. 

2  ring  curets. 

2  periosteal  elevators. 
2  sharp  retractors. 

1  mastoid  self-retaining  retractor. 

2  Mayo  retractors. 

2  mouse-tooth  forceps. 
2  thumb  forceps. 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS       187 

2  grooved  directors. 

2  probes. 

2  scalpels. 

2  scissors  (straight  blunt,  curved  blunt). 

1  needle-holder. 

12  artery  clamps  (6  curved,  6  straight). 

1  mastoid  syringe  (metal  ground,  no  washers). 

6  needles  (2  small  curved  round  body  for  possible  use 
of  catgut  Nos.  1  and  2;  4  medium-sized  full-curved  Hage- 
dorn  for  silkworm-gut  for  the  skin)  and  silk  suture  mate- 
rial. 

Accessories. — Nurses'  sponge  table  must  always  have 
scissors,  thumb  forceps,  and  in  abdominal  cases  long 
uterine  dressing  forceps  are  very  handy;  plain  gauze 
packing;  iodoform  packing;  a  nurse  usually  holds  retrac- 
tors; use  stout  needles  for  the  scalp,  but  in  a  radical  opera- 
tion use  small  round  needles  for  the  narrow,  deep  cavity; 
one  glass  basin  for  95  per  cent,  alcohol;  medicine  glass, 
smear-glasses;  slides;  swabs;  special  mastoid  dressing, 
mastoid  tips;  three  bundles  special  sponges;  towels; 
pitcher;  saline;  carbolic  acid  (5  per  cent.)  and  basin  to  steep 
an  old  syringe  with  leather  washers;  one  plug  of  iodoform 
gauze  for  the  sinus;  one  narrow  strip  of  plain  gauze  for 
the  canal. 

Notes. — Special  dark  room  or  darkened  room;  watch 
ventilation.  In  applying  bandage  move  patient  up 
until  his  shoulders  are  over  the  head  of  the  table,  then 
support  by  the  hair  and  the  shoulders;  watch  for  pus, 
and  do  not  sponge  it  away,  wait  for  a  smear  to  be  taken; 
infections  may  run  the  full  length  of  the  sternocleido- 
mastoid.  The  ward  nurse  should  be  severely  punished 
if  the  patient's  head  has  pediculi  or  if  the  hair  is  not  prop- 
erly combed  and  braided  in  the  special  mastoid  way, 
slanting  toward  the  good  ear.  The  hair  must  be  fastened 
down  along  the  edge  of  the  shaved  area  by  a  strip  of  gauze 
steeped  in  collodion,  sand-bag,  under  neck — a  special 
shaped  sand-bag,  small  and  flat. 


188  OPERATING   ROOM 

Cataract  Operation. — Instruments  generally  brought 
or  selected  by  the  operator: 

Right  or  left  speculum.         Iridectome. 

Fixation  forceps.  Cystotome. 

Cataract  knife.  Spoon. 

Iris  forceps.  Iris  repositor. 

Iris  scissors. 

Accessories. — A  bandage  (2-inch),  very  best  gauze, 
double  figure-of-8;  special  woven  woolen  or  linen  bandages, 
p.  r.  n.,  black  satin  mask  over  all;  eye  pads;  gauze  to  drop 
lens  on;  cotton  moistened  in  sterile  water  for  sponging 
leaves  no  threads;  no  pressure  on  eyeball;  assistant  must 
be  in  good  physical  shape  to  hold  the  lens  steady;  be  sure 
which  eye  is  to  be  operated  on;  cover  the  good  eye;  keep 
blood  washed  off  instruments  during  the  operation. 
All  orders  must  be  most  accurately  written  down  con- 
cerning wraps,  catharsis,  diet,  etc.  The  ethical  behavior 
of  the  hospital  staff  preceding  a  cataract  operation  has 
much  to  do  with  the  patient's  behavior  during  the  cutting. 
If  they  instil  confidence,  his  nervousness  being  reduced, 
he  will  not  "squeeze"  so  much. 

Notes. — For  nursing  cataract  cases  the  patient  must 
keep  his  orientation  by  being  told  where  he  is  taken  after 
bandaging.  When  putting  him  to  bed  the  nurse  tells  him 
which  direction  his  head  is  toward,  etc.  He  must  not 
catch  cold  and  sneeze;  there  should  be  no  draughts  on  or 
near  him;  he  must  be  lifted  more  gently  than  any  other 
patients.  Cleanse  eye  knives  in  benzine  or  in  soapy 
water  and  alcohol,  rinse  and  wipe  on  old  soft  linen.  Test 
knives  on  a  drum  for  sharpness — i.  e.,  a  kid  glove  wrist 
stretched  over  a  napkin  ring  or  a  tiny  embroidery  hoop. 
Boil  blunt  instruments  only. 

Submucous  Resection  of  the  Nasal  Septum. 

Nasal  speculum. 

Applicators,  metal,  for  the  preliminary  cocainization  to 
swab  strong  cocain  on  the  mucous  membrane;  wooden, 
previously  wound  with  cotton  on  both  ends,  for  wiping 
blood  from  the  field  during  the  operation.  Of  these 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS       189 

there  should  be  several  dozen  sterilized  and  ready  for 
use. 

Septum  knife. 

Elevators,  of  which  the  Freer  and  the  Killian'are  the 
most  common  types  (sharp  and  dull). 

Ballenger  swivel  knife  (two  sizes). 

Speculum  or  retractors  for  separating  the  flaps. 

Forceps  (various  types)  for  removing  portions  of  the 
bony  and  cartilaginous  parts  of  the  deflected  septum. 

Chisels  (flat  or  grooved,  or  both). 

Mallet. 

Septum  or  intranasal  needles  for  the  insertion  of 
sutures. 

Sutures — silk. 

Nasal  dressing  forceps. 

Gauze  strips,  iodoform  or  plain  (packing),  or  the  Beck 
rubber  nasal  packing  bags  made  on  the  principle  of  the 
Voorhees  obstetric  bags,  inserted,  filled,  and  pressing  to 
prevent  hemorrhage. 

Syringe  of  5-c.c.  capacity  if  injection  method  of  anes- 
thetization is  employed. 

Frontal  Sinus  Operation  (Radical). — A  radical  -opera- 
tion is  made  by  a  wound  between  the  brows;  an  indirect 
or  conservative  is  done  intranasally.  An  acute  infection 
at  its  first  height  may  be  successfully  treated  intranasally. 
but  a  chronic  or  neglected  acute  case  must  be  treated 
radically. 

Small  trephine;  diameter  of  not  over  5  mm. 

Scalpel. 

Thumb  forceps  (dissecting). 

Artery  clamps  (6). 

Periosteal  elevator. 

Chisels,  gouges,  and  mallet. 

Electric  burr  or  drill  is  preferred  by  some  operators. 

Curets. 

Intranasal  bone  forceps  of  various  types. 

Wound  retractors. 

Probe. 


190  OPERATING   ROOM 

Scissors  (straight  and  curved  on  the  flat). 

Needle-holder  and  silk  gut  for  the  skin  on  Hagedorn 
curved  needle. 

Radical  Operation  on  the  Ear  (Removal  of  Ossicles).— 
Same  as  Mastoid  plus: 

4  cotton  applicators. 

2  flap  knives. 

1  gauze  strip  for  retractor  (to  pull  car  forward,  out  of 
the  way). 

Specula  (graded  sizes). 

10-day  chromic  gut  No.  10. 

Accessories. — Some  men  do  a  skin-graft  into  the  middle 
ear  from  the  patient's  thigh.  Others  cover  the  graft  with 
some  fine  prepared  sterilized  animal  membrane  to  facilitate 
its  "taking." 

Jugular  Operation  Following  Sinus  Thrombosis.— 
Always  an  emergency  operation,  a  septic  thrombus  in 
the  lateral  sinus,  causing  chills  and  fever,  to  relieve  which 
a  portion  is  excised  and  collateral  circulation  established. 

Infusion  set  for  shock. 

Scrubbing-up  set. 

Saline,  cold  and  hot. 

Silk  gut. 

Blunt  retractors  (so  as  not  to  puncture  the  vein). 

An  extra  stock  of  artery  clamps. 

A  plug  of  gauze  for  the  sinus. 

lodoform  and  boric  acid  powders  in  insufflators  (sterile). 

Stout  ligatures  of  plain  catgut  No.  3  for  the  two  ends  of 
the  excised  vein. 

Note. — Save  the  specimen;  have  hot-water  bottles 
with  double  flannel  covers  in  readiness;  bandages,  2-inch 
gauze. 

Strabismus,  Operation  for. 

Speculum. 

Fixation  forceps. 

Conjunctiva  forceps  and  scissors. 

Strabismus  hook. 

Tendon  scissors  and  sutures. 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS      191 

Conjunctival  sutures — 6  black  silk  sutures,  8  inches 
long,  iron-dyed,  on  small  curved  needles — have  ready 
early. 

Enucleation  of  Eye. 

Speculum.  Stronger  scissors. 

Fixation  forceps.  Pressure  pad  (to  stop  ooz- 

Conjunctiva  scissors.  ing). 

Strabismus  hook.  Conjunctival  sutures  (see 

Tendon  scissors.  above). 

Accessories. — Two  flat  pads  of  cotton,  diameter  2J 
inches,  moistened  in  boric  acid  (2  per  cent.),  to  lay  in  the 
empty  socket,  then  dry  absorbent  cotton. 

Notes. — Mark  carefully  the  eye  to  be  enucleated  so 
that  there  will  be  no  mistake.  Cover  the  good  eye. 

Adenoids. 

Mouth-gag.  Adenoids  forceps. 

Tongue  depressor  (metal).    Adenoids  curet. 

Headlight.  6  sponge  forceps. 

Tonsils. — Add  long  blunt  scissors  curved  on  the  flat, 
tenacuium  forceps,  tonsil  snare  (or  tonsillotome,  old 
method).  Tonsil  dissecting  knives,  right  and  left,  wires 
to  thread  snare,  and  the  tonsillar  hemorrhage  needle  de- 
signed by  Dr.  Lovell  and  made  by  Ermold. 

Accessories. — Alcohol  (95  per  cent.),  adrenalin  (1 : 1000); 
rubber  cap  for  patient.  Neck  of  gown  very  loose. 
Rubber  sheet  for  turning  patient  from  left  shoulder  out 
over  chest  under  right  shoulder,  and  at  least  J  yard  out 
from  left  shoulder  again;  it  should  be  one-half  as  long 
again  as  the  patient's  measure  around  the  shoulders. 
Waste  pail  with  sieve  to  drain  sponges;  sterile  towel  over 
rubber;  laparotomy  sheet;  towels  in  a  basin  of  ice  with 
just  enough  water  to  wet  them  through;  numerous  small 
sponges  on  sponge  forceps;  severe  hemorrhages  may 
occur. 

Notes. — Protect  walls,  floor,  and  furnishings.  Do  not 
throw  out  specimens;  the  surgeon  will  want  to  show  them 
to  the  parents.  Keep  the  patient  at  the  extreme  right  of 
the  table;  wipe  his  nose  frequently  to  let  air  through, 


192  OPERATING   ROOM 

with  a  downward  stroke;  let  the  air  clot  the  vessels  in  the 
adenoid  area.  Patient  goes  down  on  the  stretcher  face 
downward,  also  in  bed. 

Pharyngeal  Abscess. — Knife,  all  the  blade  wound  with 
adhesive  except  the  first  J  inch  at  the  tip  to  prevent  its 
going  in  too  far.  If  the  patient  chokes,  use  artificial 
respiration  and  run  for  the  tracheotomy  set.  Hemorrhage 
may  ensue,  in  which  case  the  methods  after  tonsillar  hem- 
orrhage are  used.  Let  the  patient  sit  up,  if  not  anes- 
thetized, in  bed  with  a  back-rest.  Turn  him  quickly  to 
the  same  side,  so  that  pus  may  flow  down  the  same  cheek 
without  crossing  the  epiglottis. 

Accessories. — Lights,  rubber  sheet  around  patient's 
neck,  pus  basin  and  waste  pail,  mouth-wash. 

Tracheotomy. 

Scalpel. 

2  mouse-tooth  forceps. 

Artery  clamps. 

Medium  and  small  sharp  retractors. 

Small  blunt  retractor. 

Curved  and  straight  scissors. 

Probe. 

Dressing  forceps. 

Needle-holder  and  needles. 

Tracheotomy  tubes,  assorted  sizes,  with  their  inner 
tubes. 

Accessories. — Tape  in  tubes;  tie  at  one  ear;  split  com- 
presses; gauze  fluffs  wet  in  soda  bicarbonate  solution; 
oiled  silk  bib;  pheasants'  feathers.  When  the  inner 
tube  comes  out  mark  its  length  on  a  feather  and  never  put 
the  feather  in  any  farther.  Do  not  tickle  the  trachea;  do 
not  expose  the  patient's  chest  for  fear  of  pneumonia. 

Brain  Abscess  (from  Mastoiditis) . 

2  brain  knives,  curved  and  straight. 

Spade  retractors,  very  large,  square, 

Clamps. 

Encephaloscopes,  3  sizes. 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS      193 

Skin-grafting. 

Special  skin-grafting  razor  with  thin  edge,  thick  back, 
and  handle  adjusted  at  a  slant. 
Tissue  curet. 
Scissors,  blunt,  curved  on  the  flat. 

3  spatulae,  assorted  sizes. 

2  packers  (to  pick  at  skin  on  spatula). 

4  slides. 

Cotton  applicators. 

Tepid  saline  in  glass  dish. 

1  pipet. 

Sponges.     Towels. 

Roller  dressing. 

Silver  leaf  (in  book),  sterile  or  rubber  tissue. 

Flat  compresses. 

Adhesive  straps. 

Pledgets  of  aristol  (fluffed  cotton,  size  of  peas,  rolled  in 
aristol)  sterilized  in  glass  test-tubes,  and  dropped  to  place. 

Notes. — For  a  burned  area  the  scissors  or  curet  may  be 
used  to  remove  excessive  granulations.  Assistant  or 
nurse  may  keep  saline  dripping  on  razor  and  graft  (sub- 
stitute for  blood) . 

Breast  Amputation. 

Dissecting  set. 

Very  large  number  of  artery  clamps. 

Drainage-tubes . 

Ligatures  of  plain  catgut  No.  1  (very  many). 

Silk  or  silkworm-gut  for  skin  sutures. 

Tension  sutures  (silkworm-gut)  at  surgeon's  choice 
(long). 

Needle-holder. 

Needles,  usually  curved  Hagedorn  or  cutting  edge,  but 
may  be  straight  Hagedorn. 

Accessories. — Large  gauze  pads;  hot  saline  towels  on 
large  bared  area;  cotton  under  axilla,  hand,  and  at  elbow; 
4-  to  6-inch  bandages  of  gauze  and  muslin;  a  special  breast 
binder  (Figs.  24,  25)  with  a  sleeve  for  the  affected  side, 
the  sleeve  being  split  on  the  upper  side  and  fastened  with 

13 


194  OPERATING   ROOM 

tapes.  This  holds  all  the  axillary  dressing  beautifully 
secure.  Be  prepared  for  shock  and  hemorrhage.  An 
additional  nurse  holds  the  arm  above  the  patient's  head. 
Do  not  allow  the  orderly  to  be  present.  A  very  large  area 
must  be  prepared  for  this  operation,  per  the  rules  of  the 


Fig.  24. — Binder  for  breast  amputations — sleeve  spread  to  show 

pattern. 

house  as  written  in  the  standing-order  books.  Every 
vessel  is  tied  off. 

Empyema:  (a)  Aspiration,  (6)  Incision,  and  (c)  Rib 
Resection. 

(a)  Aspiration. — Unless  otherwise  specified,  the  pa- 
tient is  prepared  posteriorly  on  the  side  affected.  Set 
a  child  up  over  the  nurse's  shoulder. 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS       195 

Syringe  and  needles  in  good  order. 

lodin. 

Cotton. 

Collodion. 

Gauze. 

Large  graduate  to  measure  pus,  unsterile. 


P^-5- 

Q 


Fig.  25. — Binder  for  breast  amputations — sleeve  folded. 

Rubber  sheet  to  protect  patient  and  bed. 

Towels.  * 

Basins,  assorted,  to  hold  pus. 

Camers-hair  brush. 

Sponge  forceps. 

Small  glass  graduate,  sterile,  for  specimen  to  laboratory. 


196  OPERATING    ROOM 

(6)  Incision. — Lay  child  on  the  good  side,  resting  her 
anterior  chest  wall  on  the  pillow  (covered  with  rubber), 
bringing  her  arm  forward  so  that  she  does  not  lie  on  it. 

Scalpel. 

Hemostats. 

Ligatures,  No.  1  catgut  plain. 

Curved  scissors. 

Sharp  retractors. 

Mouse-tooth  forceps. 

Thumb  forceps. 

Drainage-tubes. 

Pus  basin. 

Graduates  (sterile,  small;  unsterile,  large). 

Note. — Note  change  in  color,  respirations,  etc.;  point 
out  all  such  data  to  juniors  for  instruction. 

(c)  Rib  Resection. — Add  to  set  in  (b) : 

Periosteal  elevator. 

Costotome  (rib-cutting). 

Bone  hook. 

Needle-holder. 

Round  needles  for  ligatures  (No.  1  catgut  plain). 

Silkworm-gut  on  curved  Hagedorn  for  skin. 

Rubber-dam  and  drainage-tube. 

Politzer  bag  and  tube  bottle  from  oxygen  tank,  the 
latter  to  produce  vacuum  and  extract  pus,  or  empyema 
button  (spool). 

Pads,  towels,  sponges. 

Unguentine  or  boraline  to  smear  over  skin  before  ap- 
plying rubber-dam. 

Appendectomy. 

Intestinal  forceps  to  grasp  colon  (Fig.  26). 

Scalpel. 

Mouse-tooth  forceps. 

Plain  forceps. 

Artery  forceps. 

Sponge-holders. 

Retractors. 

Ligature  carrier. 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS      197 


Fig.  26. — Viscera  forceps. 


Method  of  covering  jaws  with  rubber 
tubes. 


Ligatures — catgut  No.   1  for  abdominal  wall;  catgut 
No.  2,  chromic,  to  ligate  appendix. 
Scissors,  curved  and  straight. 


198  OPEKATING   ROOM 

Specimen  dish. 

Cautery. 

Carbolic  acid  and  alcohol  (pure). 

Needle-holder. 

Probe. 

Split  compress. 

Rolled  gauze  to  wall  off. 

Saline. 

Tape  sponges  with  rings  slipped  through  their  tapes. 

Drainage-tubes. 

Cigarette  drains. 

Towels. 

Towel  clamps. 

Outfit  for  lavage. 

Needles — (1)  Small  round  c  catgut  No.  1  plain  for  peri- 
toneum; (2)  stout  short  round  c  chromic  No.  2  for  muscle; 
(3)  straight  cambric  needle  or  fine  round  intestinal  needle, 
with  fine  silk  for  purse-string  suture  to  invaginate  the 
stump;  (4)  long,  heavy  curved  needles  with  silkworm-gut 
for  through-and-through  outer  sutures,  especially  if 
around  drainage-tube,  or  Michell  clips,  with  special 
forceps  (Figs.  27,  28). 

Cholecystotomy,  Cholecystectomy,  Choledochotomy. 

Dissecting  set. 

Long  stout  probes. 

Gall-stone  spoons  (Fig.  29). 

Gall-stone  forceps. 

Gall-bladder  clamp. 

Long  sounds. 

Artery  clamps. 

Ligatures  (catgut  No.  3). 

Aspirating  syringe  and  needles. 

Sponge  forceps. 

Scissors  (blunt,  curved,  straight). 

Retractors. 

Cautery. 

Carbolic  acid  and  alcohol. 

Specimen  dish. 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS      199 


Fig.  27. 


Fig.  28. 
Figs.  27,  28.— 

Michell's     suture    _, 

clips  and  forceps,    ended  gall-stone 
scoop. 


Fig.      29.— 
Mavo's  double- 


Fig.    30.— Gastro-enterostomy 
forceps— 3  blades,  13?  inches. 


200  OPERATING   ROOM 

Sterile  pus  basin. 

Drainage-tubes. 

Packing  (plain  gauze,  two  widths). 

Gauze  to  wall  off. 

Sponges. 

Tape-sponges  on  rings. 

Rubber  tissue  apron. 

Sutures  and  needles — (1)  fine  silk  on  small  round  body, 
full-curved,  for  deep  work  on  gall-bladder;  (2),  as  in 
appendectomy. 

Needle-holders,  two  sizes. 

Small  hemostatic  needle  in  opening  duct,  with  silk. 

Gastrostomy,  Gastro-enterostomy,  Gastrectomy. 

Dissecting  set. 

Retractors. 

Sponge  forceps. 

Ligatures  (chromic  Nos.  2  and  3). 

Artery  clamps. 

Ligature  carrier. 

Scissors  (curved  and  straight). 

Stomach  clamp  (Fig.  30). 

Needle-holder. 

Gauze  packing,  plain. 

Gauze  rolls  to  wall  off. 

Saline. 

Tape-sponges  on  rings. 

Sponges. 

Needles  (fine  silk  or  straight  needles,  plain  and  chromic 
catgut,  as  for  other  laparotomies). 

Drainage-tube. 

Fluffs  of  gauze. 

Cotton  pads. 

Outfit  for  lavage,  tube,  pus  basin,  pail,  pitcher  of  tepid 
water,  rubber  sheet. 

Hysterectomy. 

Dissecting  set. 

Retractors,  3  sizes. 

Clamps.  (6  long  straight,  6  long  curved,  12  small). 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS      201 

2  aneurysm  needles,  right  and  left  (Fig.  31). 

1  bladder  sound,  to  mark  the  top  of  the  bladder. 


Fig.  31.— Aneurysnr  needles,  right      Fig.    32. — Vulsellum    forceps 
and  left.  (double  tenaculum). 

6  sponge  forceps. 

Dressing  forceps  (uterine)  to  thrust  into  vagina  to  draw 
down  drain. 


202  OPERATING    ROOM 

Vulsella,  extra  strong  (Fig.  32). 

Cautery. 

Aspirating  syringe  and  needles. 

Ligatures  (braided  silk  for  pedicle;  plain  catgut  No.  2 
for  adhesions;  plain  catgut  No.  4  for  broad  ligaments). 

Pedicle  clamps. 

Blunt  scissors,  curved  on  the  flat. 

Blunt  straight  scissors. 

Sharp  scissors  (straight,  curved). 

Tape-sponges  on  rings. 

Hot  saline. 

Vaginal  packing. 

Extra  glove  for  nurse  guiding  packing. 

Sponges. 

Needle-holder. 

Sutures  (catgut  No.  1  for  flaps  on  small  curved  needle; 
catgut  No.  2  for  broad  ligament  on  half-curved  needle). 

Notes. — Be  prepared  for  collapse  when  in  Trendelen- 
burg.  Provide  many  footstools,  graded  in  height  and 
length. 

Cesarean  Section. 

Dissecting  set. 

2  large  clamps  for  the  corcl. 

2  aneurysm  needles. 

Stout  Esmarch  rubber  tourniquet. 

Sutures  of  heavy  silk  in  half-curved  needles,  fine  silk  in 
full-curved  needles. 

Placenta  basin. 

Large  floor  basins  under  the  patient's  drainage. 

Usual  sutures  for  peritoneum,  etc. 

Scissors,  straight  and  curved. 

Tape-sponges  on  rings — very  many. 

Gauze  to  wall  off. 

Hot  saline. 

Sponges  mounted  on  forceps,  very  many. 

Infant. 

Reception  blanket. 

Mouth-wipes. 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS      203 

Blow-outs. 

Cord  instruments. 

Cord,  tape,  and  binder. 

Basket. 

Hot  and  cold  tubs. 

Eye  solutions. 

Extra  physician  and  nurse. 

Hot- water  bottle. 

Pulmotor. 

Oxygen  tank  and  catheter  (intranasal). 

Note. — Be  prepared  for  hysterectomy  or  ligation  of 
Fallopian  tubes. 

Herniotomy. 

Dissecting  set. 

Hernia  knife  (Fig.  33). 

A  piece  of  sterile  tape  10  inches  long  to  slip  under  the 
cord  as  a  retractor. 

2  sharp  4-pronged  retractors. 

2  blunt  hooks. 

Artery  clamps. 

Ligatures  of  catgut  Nos.  2  and  3  plain. 

Sutures— (1)  Deepest,  kangaroo  tendon  on  medium- 
sized,  sharp,  half-curved  needles;  (2)  for  sac,  plain  catgut 
No.  2  in  medium-sized,  full-curved  needle;  (3)  silk  or  silk 
gut  for  the  skin. 

Needle-holder. 

Tape-sponges  on  rings,  hot  saline,  towels,  etc. 

Large  gauze  fluffs. 

Rubber  tissue  to  protect  dressing. 

6-inch  bandages — (a)  gauze,  -(&)  muslin.  For  inguinal 
and  femoral,  etc.,  a  spica  is  put  on  protected  with  oiled 
silk  cuffs  and  adhesive  (Fig.  34). 

Nephrectomy,  Lumbar  Route,  Nephrotomy,  Etc. 

Dissecting  set. 

Ligature  carrier. 

Clamps. 

Aspirating  syringe  and  needles  (longest  and  largest). 

Sponge-holders. 


204 


OPERATING   ROOM 


Ligatures  (rubber,  heavy  twisted  silk,  catgut  No.  4). 

Set  for  rib-resection  (costotome,  bone  hook,  periosteal 
elevator). 

Compresses  4  by  16  inches  and  from  four  to  eight 
thicknesses. 


Fig.  34. — Colostomy  bag — receptacle  for  arti- 
Fig.      33. — Hernia    ficial  anus,  soft  rubber  with  belt  adjusted  to 
knife.  left  side.     French  pattern. 

2  red  rubber  drainage-tubes,  i  by  8  inches. 

Narrow  gauze  drains. 

Needle-holder. 

Sutures — silkworm-gut  for  outer  wound  in  heavy  full- 
curved  needles;  catgut  No.  2  for  the  skin;  chromic  gut 
No.  2  for  muscles;  catgut  plain  Nos.  2  and  3  in  long  sharp 


LIST    OF    INSTRUMENTS    FOR    CERTAIN    OPERATIONS      205 


full-curved  needles,  and  small  half-curved  needles  for  the 
pelvis  of  the  kidney. 

Accessories. — Patient  lies  on  his  abdomen  on  a  kidney 
bag,  inflated,  with  the  diseased  kidney  the  higher;  instru- 
ments cannot  lie  flat  on  him;  kidney  bag  under  the  loin 
of  the  sick  side;  give  him  a  pillow  and  put  his  arms  in  a 
comfortable  position  to  prevent  paralysis.  The  nurses 


Fig.  35. — Sharp-pointed  curved  bistoury. 

should  try  this  themselves.  Surgeons  may  need  foot- 
stools. To  '  'deliver  the  kidney"  means  to  bring  it  out 
through  the  cut  with  a  "gush."  All  towels  must  be 
pinned  or  clamped.  Be  sure  that  the  work  is  on  the  sick 
kidney  (Figs.  35,  36). 


Fig.  36. — Probe-ended  bistoury. 


Curettage. 

Specula  (Sims  and  weighted). 

Vulsellum. 

Uterine  sounds  and  probes. 

Uterine  dressing  forceps. 

Packer. 

Sponge  forceps. 

Anatomic  forceps. 

Straight  scissors. 

Kelly  pad. 

Towels. 

Vaginal  sheet  and  triangles. 

Dilator. 


/ 


206  OPERATING   ROOM 

Curets. 

Intra-uterine  douche  tip. 

Rubber  tubing  for  douche  tip. 

2  iodoform  strips  1  inch  wide. 

1  iodoform  strip  3  inches  wide. 
Pad,  safety-pins,  and  T-binder. 
Douche  of  plain  sterile  water  in  irrigator  at  120°  F. 
Trachelorrhaphy. — Add  to  the  above: 
1  long  pair  mouse-tooth  forceps. 
Scalpel. 
Tenaculum. 
Artery  clamps. 

Sharp  scissors  curved  on  the  flat. 
Needle-holder. 
Cervix  needles. 

5  sutures  (silver,  wire,  and  wire  twister,  chromic  gut 
Nos.  2  and  3). 

Wire  scissors,  shield,  and  "counterpresser." 
Perineorrhaphy.— Add  to  above: 
Kelly's  crooks  (as  retractors). 

3  vulsella. 

Special  perineal  needles. 

Antiseptic  powder. 

Gauze  packing  for  vagina. 

Silkworm-gut  or  chromic  gut  Nos.  2  or  3,  or  button, 
shot,  or  silver  wire,  and  silk  to  carry  it. 

Hemorrhoidectomy. — Ligation  Method. — Local  anes- 
thesia. 

BrinkerhofPs  slide  rectal  speculum. 

Headlight  or  dfoplight. 

Pratt 's  bivalve  speculum  (to  deliver  hemorrhoidal  tu- 
mors). 

4  Halstead's    hemostats,    curved,   5    inches,    to    bite 
"spurters"  or  pull  down  tumors. 

1  pair  scissors,  curved  on  the  flat,  blunt,  6  inches  (dis- 
secting tumors  back  to  their  base). 

1  single-toothed  tissue  forceps,  7  inches  (for  removing 
"tabs"). 


LIST    OF    INSTRUMENTS    FOB    CERTAIN    OPERATIONS      207 

Tank  package  twisted  silk,  size  13,  or  catgut,  to  ligate. 

Cotton,  gauze,  " whistle"  (tampon  canula)  made  of 
rubber  tube  wound  with  gauze  and  greased  copiously. 

Wipes,  T-binder  (male  or  female),  rectal  pads. 

Sponges  on  sponge  forceps. 

Notes. — Three  25-minim  hypodermic  syringes  of  2  per 
cent,  cocain  or  novocain  with  5  drops  of  adrenalin  chlorid 
(1  :  1000)  added  to  each.  Sims  position,  nurse  or  orderly 
on  side  farthest  from  the  doctor  holds  buttocks  apart, 
sponges,  etc. 

Operation  on  Fistula  in  Ano. 

Brinkerhoff  slide  speculum. 

Lights,  etc.,  as  above.  . 

Probes,  flexible  and  plated. 

Grooved  directors,  flexible  and  plated. 

One  probe-pointed  grooved  director. 

1  Wilm's  plated  angular  director. 

Knives— 1  straight  sharp  pointed,  1  curved  sharp 
pointed,  1  straight  probe  pointed,  1  curved  probe  pointed. 

4  Halstead's  hemostats. 

1  single-toothed  tissue  forceps,  7  inches  long. 

1  pair  scissors,  sharp  straight,  10  inches  long. 

1  pair  scissors,  curved  sharp,  10  inches  long. 

1  pair  Allingham's  rectal  fistula  scissors. 

1  curet. 

Ligatures  for  bleeders. 

Gauze,  cotton,  pads,  binder,  etc.,  as  per  Hemorrhoid- 
ectomy. 

Three  hypodermic  syringes,  as  above,  for  local  anes- 
thesia. 
.     Hemorrhoidectomy. — Clamp  and  Cautery  Method. 

Speculum. 

Pile  clamp. 

Cautery. 

Mouse-tooth  forceps. 

Artery  forceps. 

Blunt  dissecting  scissors. 

Scissors  curved  on  the  flat. 


208  OPERATING   ROOM 

Scalpel. 

Special  "screw-crusher"  clamp. 

Needle-holder. 

Needles — (1)  Large  surgical  with  catgut  No.  3  to  trans- 
fix large  hemorrhoids;  (2)  straight  for  small  ones. 

Sponge  forceps. 

Catgut  ligatures  No.  2. 

Towel  on  cautery  handle. 

Sponges. 

Sponge  on  string  to  plug  rectum  during  work. 

Accessories. — lodoform  or  aristol  powder;  tampon 
canula  or  " whistle"  well  lubricated;  split  compress; 
gauze;  binder;  vaselin;  soapsuds  for  cleansing,  saline  to 
follow;  rubber  apron;  Gant  pads. 


CHAPTER  XV 
NOMENCLATURE 

"Call  a  spade  a  spade." 

Terms  Created  by  the  Workers  of  the  Operating  Room  in  Contra- 
distinction to  the  Terms  Used  in  Surgical  Diagnosis  or  Pathology. 

To  the  young  nurse — Warning!  Be  hereby  advised 
never  to  use  any  term  relative  to  nursing  (or  anything 
else,  for  that  matter)  whose  meaning  you  do  not  under- 
stand well  enough  to  give  a  reasonable  explanation  to 
the  surgeon  who  knows  a  great  deal  more  than  you  do 
about  it,  or  to  the  junior  nurse  who  knows  less,  and  has 
a  way  of  asking  very  embarrassing  questions. 

There  are  many  pupils  whose  previous  training  in 
English  was  of  the  most  circumscribed  proportions  (what 
is  the  English  of  one  year  in  high  school?)  arid  yet,  in  a 
hospital,  they  come  out  boldly  with  long  terms  which 
they  can  neither  define  nor  spell  correctly.  But  this  can 
be  mastered,  and  is  no  reason  why  they  should  not  be 
used  in  their  proper  place.  Some  pupils  with  the  limited 
vocabulary  aforesaid  pick  up  these  words  and  play  with 
them  as  with  a  new  toy,  reiterating  them  until  others  who 
can  speak  English  well  are  bored  to  death.  Learn  the 
derivation  of  all  these  terms,  and  employ  them  only 
when  that  will  save  time  by  being  concise.  The  well- 
educated  gentleman  is  master  of  many  languages,  but  uses 
only  the  simplest  Saxon.  Plain,  simple  Saxon  is  much 
more  forceful  and  figurative  than  words  of  classic  origin. 

There  are  certain  Latin  and  Greek  roots,  not  many  in 
all,  that  are  used  as  a  basis  for  all  the  terms  describing 
the  operations  that  are  performed,  and,  added  to  the 
classic  roots  that  name  the  different  parts  of  the  body, 

14  209 


210  OPERATING   ROOM 

show  at  a  glance  the  entire  proportions  of  the  work  done. 
The  name  of  the  operation  appears  only  about  five  times 
per  case: 

(1)  When  it  is  posted  in  the  office  or  the  operating-room 
calendar. 

(2)  When  the  supervisor  drills  the  pupils  who  are  to 
assist  in  the  anatomy  of  the  parts  concerned  so  as  to 
select  the  proper  instruments  and  materials. 

(3)  On  the  slip  sent  down  to  the  ward  briefly  specify- 
ing the  salient  features  of  the  whole  affair  for  the  imme- 
diate enlightenment  of  the  nurse  who  is  to  take  care  of 
the  ether  patient. 

(4)  On  the  chart  in  three  places — (a)  opposite  the  hour 
when  it  took  place  in  the  day's  sequence  of  events;  (b)  on 
the  patient's  discharge  slip;  (c)  and  on  the  history  sheet 
written  up  at  full  length  by  the  intern. 

(5)  And,  lastly,  in  the  register  kept  by  the  operating 
supervisor  of  all  cases. 

Model  of  slip  sent  to  ward  with  ether  case: 

1.  Date. 

2.  Patient's  name. 

3.  Ward  whence  patient  came. 

4.  Operator. 

5.  Operation. 

6.  Anesthetic. 

7.  Stimulation. 

8.  Drainage. 

9.  Condition. 

The  word  used  to  signify  the  disease  or  cause  for  opera- 
tion may  be  entirely  different  from  that  describing  the 
process  of  cutting,  sawing,  or  sewing;  and,  again,  some- 
times a  correct  diagnosis  cannot  be  made  until  the  opera- 
tion is  almost  complete.  Again,  the  same  operation  may 
be  performed  for  two  entirely  different  conditions.  To 
illustrate  the  first,  we  all  know  what  a  cleft  palate  is,  but 
the  operation  to  repair  it  is  called  staphylorrhaphy. 
Second,  an  opacity  of  the  lens  of  the  eye  is  called  cataract. 
The  tense,  hard  condition  of  the  eye  due  to  certain  glandu- 


NOMENCLATURE  211 

lar  secretions  being  blocked  at  their  proper  outlet  is  called 
glaucoma.  But  both  cataract  and  glaucoma  are  relieved 
by  iridectbmy.  To  distinguish  carefully  between  these 
is  a  necessary  feature  in  the  supervisor's  instruction;  e.  g., 
ectomy  means  cutting  away  entirely,  while  otomy  means 
cutting  into.  In  a  different  chapter,  on  Surgical  Diag- 
nosis, the  terms  describing  the  pathologic  conditions 
causing  operation  are  given.  If  one  is  asked  what  was 
the  nature  of  the  operation,  she  should  bravely  say,  "He 
had  his  gall-bladder  removed"  if  she  cannot  remember 
"cholecystectomy,"  but  she  should  not  say  "cholecysti- 
tis" and  miss  the  mark.  To  make  the  names  of  all  opera- 
tions place  the  name  of  the  anatomic  part  first,  of  Latin 
or  Greek  derivation,  and  the  foreign  root,  describing  the 
work  to  be  done,  last.  It  is  better  for  pupils  to  know  a 
few  classic  roots  and  "make  their  own  terms"  than  to 
swallow  unsearched,  unprobed,  and  unknown  a  bowlful 
of  ready-made  terms.  Knowing  the  why  and  the  where- 
fore of  everything  warms  the  cockles  of  the  heart  in  an 
otherwise  dull  existence. 

Greek  words  are  mostly  used  for  the  thing  done, 
whether  cutting  out,  or  sewing  up,  or  cutting  into  for 
drainage,  and  Latin,  generally  but  not  always,  for  the 
anatomic  part  operated  on.  In  making  up  new  words 
it  is  well  to  remember  the  rule:  Double  the  final  con- 
sonant after  a  short  vowel,  as  benefit,  benefitted;  label, 
labelling.  When  one  has  built  up  a  new  term  and  re- 
ceived the  supervisor's  O.  K.  for  pronunciation  and  spell- 
ing, the  whole  term  should  be  written  ten  times  or  so  for 
practice.  This  is  one  feature  that  makes  the  operating- 
room  pupils  the  despair  and  envy  of  the  remainder  of  their 
class  in  recitation. 

Adeno,  relating  to  glands — of  the  neck,  axilla,  etc. 

Chole,  relating  to  bile. 

Colo,  pertaining  to  the  colon,  part  of  the  large  intestine. 

Colpo,  relating  to  the  vagina;  there  are  few  terms  begin- 
ning with  vag  to  denote  any  operation. 

Cranium,  the  skull,  or  bony  covering,  not  the  brain. 


212  OPERATING   ROOM 

Gastro,  pertaining  to  the  stomach. 

Hysteron,  the  uterus. 

Jejun,  relating  to  the  second  part  of  the  small  in- 
testine. 

Lamina,  a  plate  or  layer  (posterior  vertebral  arch). 

Nephron,  the  kidney. 

Odphoron,  the  part  bearing  the  egg  (Greek,  the  ovary). 
Note  the  pronunciation  and  spelling,  also  the  dieresis  which 
is  used  to  divide  two  vowels  that  would  otherwise  be  pro- 
nounced together  as  a  diphthong  (oo  is  pronounced  like  oa 
in  oasis). 

Ophthalmo,  relating  to  the  eye. 

Orchi,  relating  to  the  testicle  (genito-urinary ) . 

Osteo,  bone  (Latin,  os,  ossa).  There  are,  of  course, 
many  bones  and  many  varieties  of  operations  on  bones, 
the  particular  part  diseased  being  specified — e.  g.,  oste- 
otomy, division  of  a  bone,  but  which  one  must  be  speci- 
fied. 

Ot,  pertaining  to  the  ear. 

Prod,  relating  to  the  rectum. 

Prostat,  relating  to  the  prostate  gland  (genito-urinary). 

Rhino,  pertaining  to  the  nose. 

Salpinx,  the  tube. 

Spermato,  relating  to  the  semen. 

Tars,  pertaining  to  the  instep. 

Ten,  pertaining  to  a, tendon  (in  tfeeye,  wrist,  etc.). 

Trachelo,  relating  to  the  cervix  or  neck  of  the  uterus. 
There  is  no  word  beginning  with  cervi  to  denote  an  opera- 
tion on  the  cervix. 

Tracheo,  pertaining  to  the  windpipe  only. 

Uretero,  relating  to  the  two  pipes  or  tubes  from  the 
kidneys  to  the  bladder. 

Urethr,  relating  to  the  one  canal  from  the  bladder  to 
the  outside. 

Vas,  the  sperm  duct. 

The  few  classic  words  describing  the  work  done,  or 
the  mechanical  process  in  which  instruments  are  em- 
ployed, may  each  be  added  to  any  and  every  one  of  these, 


NOMENCLATURE  213 

making  a  now  far  from  bewildering  but  very  extensive 
vocabulary.  To  have  three  new  words  radiating  from 
each  of  the  above  terms — gastrostomy ,  gastrotomy,  gas- 
tredomy— means  quite  a  variety  in  operating-room  ex- 
perience also.  The  clever  nurse  reckons  her  work  up  as 
follows:  "I  have  scrubbed  for  three  appendices,  one 
mastoid,  two  hernias,  and  one  gastrostomy  already,"  or 
again,  "I'm  nearly  through  my  service  and  I  haven't  had 
an  iridectomy  or  a  hysterectomy." 

-ectomy  (Greek,  cutting  off),  a  complete  removal  of  a 
part. 

-orrhaphy  (Greek,  suture),  a  sewing  up. 

-ostomy  (Greek,  stoma,  a  mouth),  making  a  new  opening 
out  of  an  organ;  usually  a  new  path  to  pass  the  intestinal 
contents  along  in  order  to  get  by  an  obstacle,  usually  a 
malignant  growth. 

-otomy  (Greek,  to  cut),  a  cutting  into  for  drainage. 

-plasty  (Greek,  meaning  form  or  shape),  cutting  and 
trimming  off;  straightening  and  smoothing  for  some  pur- 
pose. 

Sometimes  operations  are  named  after  the  first  great 
pioneer  who  performed  them,  but  the  latest  authorities 
agree  that  proper  names  should  be  banished  both  in 
anatomy  and  surgery,  therefore  only  one  of  the  names 
of  those  great  surgeons  will  be  mentioned  here,  much  as 
one  would  willingly  add  to  their  laurels.  A  strong  effort 
should  be  unitedly  made  to  abolish  this  foolish,  confus- 
ing custom.  In  anatomy,  the  parts  should  be  named 
according  to  where  they  are  and  what  they  do.  In 
surgery,  the  operation  should  be  named  according  to  the 
part  affected  and  the  work  effected.  Simple,  concise 
terms,  founded  on  the  primary  studies  of  the  medical 
student,  will  bring  the  surgeon  into  closer  touch  with 
the  general  practitioners  who  herd  the  cases  in  his  direc- 
tion, and  with  the  nurses  who  are  his  earnest  hand- 
maidens. 

There  are  many  special  terms  used  in  the  operating 
room  relating  to  action  rather  than  to  passive  conditions, 


214  OPERATING   ROOM 

which,  therefore,  find  a  more  fitting  place  in  this  than  in 
the  chapter  on  Surgical  Diagnosis.  There  are  also  cer- 
tain words  formed  according  to  the  rules  above  given 
whose  pronunciation  and  spelling  are  unique.  Other 
names  are  misnomers,  due  to  slipshod  methods.  Some 
names  are  compounded,  part  upon  part,  on  account  of  the 
masterful  efforts  made  by  some  of  these  modern,  radical 
" trouble  men,"  as  they  call  the  mechanics  in  the  garages, 
who  can  fix  anything  that  is  wrong  in  an  automobile. 
Some  of  the  words  listed  are  of  diagnoses  often  confused 
with  operations.  The  number  is  far  from  complete,  and 
on  the  blank  pages  following  should  be  inserted  all  the 
new  words  each  nurse  hears,  with  its  definition.  Some 
require  the  insertion  of  an  extra  vowel  for  smoothness  of 
sound. 

Adenoids.  Hypertrophied  tissue  in  the  nasopharynx. 
Note  also  the  spelling  of  "pharynx";  y  is  the  same  in  value 
and  pronunciation  as  i;  "rynx"  =  rinks.  Pronounce  like 
far  inks. 

Anastomosis  means  a  joining,  end-to-erid,  as  of  two 
pieces  of  gut. 

Bloodless  operation.  Usually  the  name  given  to  the 
method  employed  to  straighten  the  limbs  in  congenital 
hip-disease.  There  is  no  external  wound;  the  bones  are 
broken  by  manual  force,  without  instruments,  and  the 
child  immobilized  in  a  "frog"  of  plaster  of  Paris,  the  posi- 
tion being  "overcorrected"  or  exaggeratedly  changed. 

Bone-grafting  or  Bone  inlay.  A  quite  recent  discovery; 
splicing  an  old,  diseased  bone  with  a  sound  piece;  taken 
usually  from  the  tibia  to  repair  a  tuberculous  spine. 

Bone-plating.  A  metal  plate  (the  sizes  vary)  is  screwed 
in  place  with  steel  screw-nails  to  join  two  ends  of  broken 
bone. 

Burns  or  scars  from  other  accidents  are  atoned  for  by 
skin-grafting — a  plastic  operation. 

Cesarean  section.     Note  the  spelling  (obstetric  term). 

Clamp  and  cautery.  Slipshod  name  for  a  certain  opera- 
tion to  remove  hemorrhoids. 


NOMENCLATURE  215 

Coccygectomy.  Pronounce  kok-sig-jec-tomy.  Note  the 
spelling;  a  very  simple  operation,  as  the  name  shows. 

Craniotomy.     Obstetric  term. 

D.  and  C.  A  cloak  for  abortions  that  are  not  neces- 
sary sometimes. 

Dilatation.     "Dilation"  is  quite  as  correct. 

Excise.  To  cut  off,  to  remove,  especially  what  is  seated 
near  the  surface. 

Extirpate.     To  cut  away  or  remove  what  is  deep  seated. 

Gastro-enterostomy.  An  opening  from  the  stomach  into 
the  intestine,  usually  the  jejunum,  to  get  past  some  ob- 
struction above  the  latter;  an  illustration  of  a  compound 
word. 

Immobilize.  To  fix,  to  render  motionless,  with  a  splint, 
a  plaster  cast,  or  sand-bags. 

Incise.     To  cut  into,  as  into  a  boil,  for  drainage. 

Iridectomy.  A  misnomer;  should  be  qualified  by  the 
term  "partial"  or  ' 'incomplete."  The  whole  iris  is  not 
removed  unless  the  rest  of  the  eye  goes  with  it.  A  tiny 
piece  only  is  cut  out,  leaving  a  black  patch  which  is  a  con- 
tinuation of  the  pupil,  the  whole  resembling  and  some- 
times called  a  "keyhole." 

Jejunojejunostomy.  Sewing  two  parts  of  the  same  gut 
together  and  making  a  mouth  afterward  at  the  point  of 
junction  so  as  to  catch  any  portion  of  the  intestinal  con- 
tents lurking  in  the  "vicious  circle,"  like  a  plumber's  trap, 
left  above  after  a  gastrojejunostomy,  as  can  easily  be 
seen  by  a  drawing. 

Kraske.  The  name  of  the  surgeon  who  relieved  cancer 
of  the  rectum  by  removing  the  coccyx  and  part  of  the 
sacrum  to  form  a  new  opening  above  the  malignant 
growth. 

Ligation.  A  term  for  one  kind  of  hemorrhoid  opera- 
tion; tying  off  the  dilated  vessels  and  excising. 

Myringotomy.  Cutting  through  the  ear  drum  for 
drainage. 

Needling.  An  operation  on  the  eye,  done  as  a  sec- 
ondary to  the  primary  iridectomy;  lacerating  a  cataract 


216  OPERATING   ROOM 

with  a  needle  to  afford  entrance  to  the  aqueous  humor 
and  cause  absorption  of  the  lens. 

(Esophagectomy,  (Esophagotomy.     Note  the  spelling. 

Panhysterectomy.  Extirpation  of  the  whole  uterus, 
in  distinction  from  hysterosalpingo-oophorectomy  (three 
o's  together),  which  means  the  removal  of  uterus,  tubes, 
and  ovaries. 

Plastic.  Sewing,  trimming  off,  etc.,  for  repair  and 
cosmetic  effect. 

Pyloroplasty .     Sewing  and  cutting  around  the  pylorus. 

Resection.  Wrongly  used,  to  mean  taking  a  piece  of 
rib  out,  to  produce  drainage  for  empyema. 

Splenectomy.  It  is  interesting  to  know  that  man  can 
live  after  certain  organs  like  the  spleen  have  been  taken 
out. 

Staphylorrhaphy.     Operation  for  cleft  palate. 

Tonsillectomy.  The  new  method  of  removing  the 
whole  tonsil  by  snaring  it  at  its  base. 

Tonsillotomy.  Old  method  of  cutting  off  the  top  of  a 
tonsil. 

Trephine  or  Trepan.  Sawing  into  the  skull,  generally  in 
three  rings  or  disks,  to  break  off  the  small  bridges  remain- 
ing without  much  jar  to  the  patient. 


CHAPTER  XVI 

LINEN   OF  THE   OPERATING  ROOM 

IT  is  quite  easy  to  calculate  how  much  linen  of  every 
kind  is  needed  for  an  operating  room.     This  depends  on — 

(1)  The  kinds  of  cases  and  the  articles  each  requires. 

(2)  The  number  of  cases  per  day. 

(3)  The  number  of  nurses  and  the  amount  of  time  at 
their  disposal  to  refold,  put  up  in  covers,  and  sterilize. 

(4)  Fractional  sterilization. 

(5)  The  speed  at  which  the  laundry  operates  for  the 
surgical  service. 

(6)  A  possibility  of  illness  among  the  nurses. 

(7)  A  possibility  of  breakdown  or  repairs  in  the  steril- 
izers. 

(8)  An  abnormal  rush  in  the  service  at  certain  seasons. 
To  start  with  a  great  deal  of  linen  is  not  going  to  wear 

it  out  faster,  and  it  is  a  great  gain  to  the  supervisor's 
anxious  mind.  But  she  should  have  an  inventory  of  all, 
and  a  perfect  system  of  exchange  in  cooperation  with  the 
central  linen  room,  which  exchanges  at  its  own  pleasure 
for  the  rest  of  the  house,  but  at  her  pleasure  for  her  service. 
Patching  all  holes  is  absolutely  imperative.  A  steril- 
ized towel  is  not  of  any  use  if  it  has  a  hole  in  it.  But 
patches  are  no  disgrace  and  offer  no  disadvantage.  On 
the  contrary,  to  put  on  patches  and  to  use  patched  goods 
are  essential  in  a  nurse's  training.  Whether  the  nurse 
does  this  as  a  part  of  her  operating-room  experience,  or 
in  her  course  on  housekeeping  under  the  matron,  is  a 
matter  of  indifference  so  long  as  she  does  it  some  time. 
Uniformity  is  of  great  advantage  both  for  appearance 
and  speed  of  work.  It  is  pleasant  to  see  some  harmony 
between  the  color  of  walls,  table,  towels,  and  stains  in 

217 


218  OPERATING    ROOM 

carbolic  acid  or  bichlorid  (as  warnings  for  poisons).  If 
towels  were  originally  a  red  check,  and  it  is  desired  to 
change  to  a  blue  check,  give  all  the  red  checks  to  the 
wards  and  buy  the  blue  outright. 

White  linen  is  preferable  for  gowns  and  caps,  since  it 
always  looks  so  snowy.  There  is  no  good  excuse  for  the 
very  bad  color  of  most  linen,  since  the  reason  is  a  bad 
one.  Operating-room  linen  should  be  bleached  in  the  sun, 
especially  in  slack  times,  being  dried,  then  sprinkled  down, 
and  dried  again  many  times,  as  the  Dutch  women  do. 
But  it  is  mostly  dried  in  the  driers  and  never  gets  a  whiff 
of  fresh  air,  soon  becoming  stuffy  and  dark.  There  are 
many  bleaches  put  on  the  market  and  many  washing  fluids 
patented  which  are  supposed  to  whiten  linen  without 
labor,  but  that  sort  always  eats  away  the  goods.  A 
gown  or  uniform  frays  in  six  months  or  less  if  laundered 
with  bleaches.  By  having  an  extra  lot  of  gowns  and 
bleaching  them  with  sunshine  money  is  saved  in  large 
quantities.  A  good  system  for  operating-room  linen 
laundering  is  as  follows: 

(1)  The  linen  is  sent  down  with  all  clots  and  stains 
soaked  out  in  cold  water  and  put  then  into  the  machines. 

(2)  Rinse  cold  twenty  minutes. 

(3)  Warm  water  and  soap   twenty  minutes;  wash  by 
machinery. 

(4)  Warm  rinse  ten  minutes. 

(5)  Hot   water   and   soap    thirty    minutes;    wash   by 
machinery. 

(6)  Hot  rinse  five  minutes. 

(7)  Hot  rinse  five  minutes. 

(8)  Hot   water  and  4   ounces   of  acetic  acid  to  the 
machine,  ten  minutes. 

(9)  Cold  water,  add  the  blue,  ten  minutes. 

Most  laundries  neglect  rinsing.  Frequent  rinsings 
clear  linen  better  than  anything  else.  Wyandotte  soda 
with  chipped  soap  precipitates  lime  salts.  These  are 
bought  by  the  barrel.  Anilin  blue  (No.  90)  in  1-pound 
cans  is  purchased  for  the  coloring.  Flannel  covers  for 


LINEN    OF    THE    OPERATING    ROOM  219 

masks  should  be  washed  with  green  wool  soap  and  rinsed 
thoroughly  in  water  with  a  little  glycerin  added,  then 
hung  in  the  fresh  air  with  the  stripes  vertical.  Gowns  fre- 
quently lose  their  tapes,  and  it  is  not  to  be  wondered  at 
when  one  sees  the  inside  of  a  washing-machine;  they 
should,  therefore,  be  washed  in  open  net  bags,  similar  to 
those  for  nurses'  handkerchiefs,  to  prevent  tearing  or  loss. 
Dome  fasteners  are  better  than  buttons.  These  little 
details  of  repair  should  be  done  by  the  nurses  who  scan 
the  articles  closely  as  they  prepare  them  for  refolding. 
Scultetus  binders,  straight  abdominal,  and  breast  binders 
must  be  well  ironed.  The  nurses'  course  in  the  hospital 
is  not  complete  without  having  had  one  month  under  a 
competent  housekeeper,  where  they  learn  all  these 
things,  with  an  eye  to  future  positions  of  their  own,  but 
the  present  benefit  to  their  training-school  and  hospital 
is  a  sympathy  with  the  office  in  its  enormous  outlay,  with 
those  humble  employees  who  labor  for  them,  and  a  de- 
termination not  'to  be  extravagant. 

Every  operating  room  should  have  its  book  of  measures 
and  patterns  with  samples  of  goods  and  lists. of  firms  fur- 
nishing these,  their  prices,  discounts,  and  length  of  time 
in  delivering.  There  should  be  a  set  of  stencils  for  mark- 
ing goods,  whether  those  made  by  'hand  in  the  workroom 
or  grown  dim  with  frequent  laundering.  The  study  of 
standards  of  weight  in  various  kinds  of  cloth,  such  as 
Ca'nton  flannel,  unbleached  muslin,  etc.,  and  thread 
gauges  in  gauze  forms  interesting  and  valuable  work  to 
the  pupil. 

SPECIAL  ARTICLES 

Men's  T-binders  are  not  like  those  for  women.  The 
perineal  strap  is  split  in  two,  so  as  to  come  up  at  each 
side  of  the  genitals.  The  edges  are  all  carefully  turned 
in  and  stitched,  and  at  the  upper  end  of  the  split  a  crow's 
foot  stitched  in  to  prevent  a  tear.  The  sizes  should  vary 
according  to  the  waist  measure,  since  men  vary  so  in 
stature  and  girth. 

Men  should  wear  suspensories  if  to  be  confined  in  bed 


220  OPERATING   ROOM 

flat  on  their  back  for  any  length  of  time.  These  can  be 
bought,  assorted  sizes,  and  put  on  in  the  operating  room 
at  once  after  operation.  If  not  purchased  wholesale  at  a 
low  rate,  they  can  be  .made,  by  the  aid  of  scissors  and  a  few 
safety-pins,  out  of  a  couple  of  yards  of  4-inch  muslin 
bandage.  If  not  applied,  the  long-continued  horizontal 
position  causes  certain  inflammation. 

Laparotomy  gowns  and  stockings  are  made  of  thick 
soft  Canton  flannel.  The  gowns  are  opened  at  the  back 
with  tapes,  not  buttons,  and  the  stockings  go  with  them  in 
sets.  Each  set  should  be  folded  so  as  to  show  its  mark — 
A.  B.  Hospital,  lap.  gown  and  sox,  4  ft.  6  in. — 54  inches 
being  the  total  length  of  the  set,  it  can  easily  be  adjusted 
to  the  height  of  the  patients.  The  stockings  should  not 
be  folded  separate  from  the  gowns.  Just  as  soon  as  the 
case  is  over,  a  set  which  has  been  warming  in  the  blanket 
warmer  or,  failing  that,  on  the  radiator  should  be  put  on 
instead  of  the  one  already  wet  with  perspiration. 

Scultetus  binders  are  made  of  Canton  flannel.  Noth- 
ing else  will  do.  The  piece  for  the  back  should  be  for  an 
adult,  from  12  to  15  inches  long  and  7  to  9  inches  wide, 
not  allowing  for  the  making.  It  must  be  double,  there- 
fore is  most  easily  made  by  taking  a  piece  24  inches  long 
and  folding  it  once  crosswise,  and  basting  it  along  the 
edges  and  down  the  center  to  keep  it  straight  while 
setting  in  the  " tails."  There  should  be  ten  tails,  five  on 
each  side,  overlapping  about  1  whole  inch.  The  tails 
are  cut,  not  torn,  and  are  overcast  finely,  not  hemmed,  on 
all  edges  by  hand.  The  fold  in  the  back  piece,  as  in 
all  binders,  indicates  the  bottom.  The  patient  must  not 
lie  on  a  seam.  Five  tails  are  set  in  on  one  side  with  pins, 
extending  inside  the  back  piece  about  f  inch,  for  security 
in  the  braiding  effect  afterward.  The  basted  edges  of  the 
back  piece  are  then  turned  in  and  the  whole  basted 
through,  taking  care  to  remove  all  pins.  The  tails 
must  all  overlap  an  equal  amount  and  in  the  same  direc- 
tion as  well  as  in  the  same  manner.  The  opposite  side  is 
done  similarly,  taking  care  that  the  tails  will  be  set  in  in 


LINEN    OF   THE    OPERATING    ROOM  221 

exactly  the  same  way,  so  that  both  sides  will  look  alike. 
Taking  up  the  binder  both  sides  should  overlap  down- 
wardly or  both  upwardly,  otherwise  it  never  can  be  put  on 
properly.  It  takes  a  long  time  to  make  one  Scultetus 
binder,  and  if  the  nurses  do  it  in  classes  they  will  never 
be  guilty  of  cutting  one  to  let  a  drainage-tube  through. 
In  one  instance  it  took  a  class  of  six  nurses  one  hour  to 
make  one  Scultetus  binder  as  a  lesson.  As  to  the  width  of 
the  tails,  for  a  binder  of  12  inches  depth  each  of  the  five 
tails  should  be  4  inches  wide  and  overlap  1  inch  each. 
As  to  the  length  of  the  tails,  they  should  come  from  the 
back  piece  on  one  side,  across  the  abdomen  and  back  to 
the  other  side  of  it,  that  is,  once  the  measure  of  the 
patient's  girth  less  the  width  of  the  back  piece.  If  a 
patient  is  40  inches  around  the  abdomen,  and  we  make 
a  back  piece  8  inches  wide  when  finished,  the  tails  should 
all  be  32  inches  long  (not  counting  the  making).  Sculte- 
tus binders  should  be  made  in  all  sizes,  first  measuring  a 
few  patients  with  thick  cotton-pads  and  piles  of  gauze 
dressings  to  get  them  correct. 

A  maternity  breast  binder  with  a  plain  sleeve  added 
makes  an  ideal  dressing  for  a  breast  amputation.  Make 
a  sleeve  of  the  ordinary  men's  coatsleeve  style  of  double 
unbleached  muslin,  but  open  it  on  the  outer  surface  of 
the  arm  in  a  line  running  from  the  ring  finger  to  the  tip 
of  the  acromion  process  (when  the  palm  of  the  hand  is 
downward).  This  opening  is  closed  with  tapes,  four  on 
each  side,  about  8  inches  long.  It  corresponds  with  the 
opening  at  the  shoulder  of  the  breast  binder,  whose  flaps 
extend  about  1  inch  past  the  sleeve  on  each  side.  The 
dressings  of  the  axilla  are  easily  kept  in  place  and  the 
binder  may  be  reversed.  The  sleeve  need  not  extend  be- 
low the  elbow.  (See  Figs.  24  and  25.) 

Caps  should  be  of  light  weight  material,  but  firm.  If 
very  slightly  starched  rather  thin  material  will  do,  espe- 
cially in  summer.  The  pill-box  type  fits  so  closely  that 
perspiration  flows  more  freely,  whereas  a  tall  wedge  cap 
keeps  the  head  rather  cooler  (Fig.  37). 


222 


OPERATING   ROOM 


Masks  should  be  made  of  heavy  dimity,  but  nothing 
heavier  than  that,  since  even  the  sheerest  is  intensely  un- 
comfortable. 

Laparotomy  sheets  should  have  an  opening  not  more 
than  10  inches  long  and  6  inches  wide,  making  at  any 


Fig.  37. — A  becoming  cap  to  either  doctor  or  nurse. 

time  required  about  a  16-inch  ellipse;  for  example,  in 
cesarean  section.  The  sheet  should  be  long  and  wide 
enough  to  extend  over  the  body  of  a  very  fat  patient  and 
reach  down  not  farther  than  3  inches  below  the  surface 
of  the  table.  If  a  patient  is  very  tall,  an  extension,  in 
the  shape  of  a  table  cover,  may  be  used  for  the  feet. 


LINEN    OF    THE    OPERATING    ROOM 


223 


Laparotomy  sheets  should  be  of  assorted  sizes,  with  the 
exception  of  those  for  small  babies,  when  a  large  towel 
may  be  slit  in  the  manner  described. 

Vaginal  sheets  of  the  style  shown  in  the  illustration 
(Fig.  38)  are  abundantly  required,  and  can  be  easily  put 


Fig.  38. — Vaginal  sheet. 

on  or  removed  after  the  vaginal  work  is  done.  The  sheet 
goes  on  over  the  sterile  triangles  which  cover  the  stirrups. 
This  is  so  secure  that  it  makes  a  sterile  table  cover  over 
the  abdomen  for  instruments,  and  is  much  less  confusing 
than  a  number  of  towels  and  clamps. 


224  OPERATING   ROOM 

Triangles  and  sheet  are  folded  in  sets  in  such  a  manner 


that  the  two  former,  each  into  half  a  square,  fit  together 
on  top  o?  the  square  sheet  and  make  a  very  good-looking 


LINEN    OF   THE    OPERATING    ROOM  225 

package.  A  triangle  is  an  unbleached  muslin  cone  to 
cover  the  leg  and  thigh. 

For  tubes  of  packing  it  is  a  waste  of  time  to  roll  them 
tightly  in  a  wayward  square  cover.  Make  a  long  narrow 
double  tubular  bag  (Fig.  39,  6),  with  a  drawstring  at  the 
neck,  and  put  the  tube  in  it.  Of  these  there  should  be 
many,  one  for  each  tube  in  the  sterile  stock,  one  clean 
extra  for  each,  one  being  laundered,  etc.  All  dressing 
covers,  including  these  bags,  should  be  very  frequently 
laundered  and  bleached  to  counteract  the  burning  they 
get  in  the  sterilizers. 

Gown  Covers. — Again,  it  is  a  pity  to  ask  a  nurse  to  tug 
with  gowns  (Fig.  39,  a).  Rather  provide  covers  specially 
for  the  gowns.  Each  should  have  a  double  cover  with  a 
flap  and  boxed  edges,  somewhat  resembling  a  square 
cushion,  and  dome  fasteners.  This  saves  much  time  and 
vexation.  These  are  particularly  nice  for  a  private 
physician's  kit.  Glove  envelopes  are  referred  to  in  Care  of 
Rubber  Gloves,  chapter  on  Formulae  and  Directions 
(Fig.  39,  d). 

Folding  Linen. — There  are  two  methods-  of  folding 
linen.  By  one  the  article  is  taken  at  its  full  length  and 
folded  often  enough  to  be  a  convenient  width — a  towel 
once,  a  gown  twice — then  simply  plaited,  so  that  it  may 
drop  to  its  full  length  by  only  gently  lifting  one  edge 
(Fig,  40).  When  a  doctor  is  putting  on  a  gown  it  is  pre- 
sented to  him  with  the  collar  uppermost.  He  takes  it  by 
the  collar  in  a  clear  space  in  the  room,  and  as  he  raises  it 
it  drops  its  full  length.  But  the  trouble  with  this 
method  also  arises  from  that  very  feature.  Things 
opening  too  easily  might  be  easily  contaminated.  The 
one  counterbalances  the  other.  The  second  method  is  to 
fold  the  article  from  its  ends  toward  its  center  so  as  to 
control  it  perfectly. 

To  fold  a  towel  24  by  30  inches  or  of  similar  proportions, 

lay  k-o  over  on  a-e,  pressing  the  fold  f-j  firmly.     Bring 

the  double  edges  a-k  to/  and  e-o  toj  to  the  center  c-m  to  h, 

almost,  but  not  quite,  to  prevent  a  hump.    Now  fold  from 

15 


226 


OPERATING    ROOM 


b-l  to  g  and  d-n  to  i  to  the  center  again.  Then  fold  to- 
gether. In  opening  this  towel  hold  the  folds  at  d  and  at  b 
in  the  right  and  left  hands  respectively,  between  the  fore- 
finger and  second  finger.  Hold  the  points  at  a  and  e 
between  forefinger  and  thumb  also.  Keep  the  two 
thumbs  close  together  and  the  whole  towel  compressed 
until,  having  wedged  a  way  between  two  assistants,  one 
has  space  close  beside  the  area  to  open  the  towel  out  sud- 


Fig.  40. — Gown  and  towel  plaited  in  one  direction — opening  too 
easily  with  one  movement. 

denly  like  a  fan  and  lay  it  in  situ.  This  method  keeps  the 
whole  bottom  edge,  k-l-m-n-o,  securely  fastened  be- 
tween the  thumbs  until  needed  (Fig.  41). 

In  folding  gowns,  hold  by  the  under  arm  seams  and  let 
drop  longitudinally  into  four  thicknesses.  The  nurse 
keeps  the  under  arm  sides  next  to  her  and  makes  them  the 
straight  edge.  The  sleeves  are  turned  (together)  at  a 
sharp  right  angle  to  this  line,  straight  across  the  gown,  and 


LINEN    OF    THE    OPERATING    ROOM 


227 


when  they  reach  the  opposite  edge  sharply  folded  back  on 
themselves,  perfectly  flat  and  square.  Do  not  bring  the 
sleeves  down  along  the  body  of  the  gown.  Turn  in  tapes 
into  the  inner  part  of  the  openings  on  the  farther  edge. 
Fold  from  the  collar  and  the  bottom  in  almost  to  the  cen- 
ter. By  leaving  1  inch  in  the  middle  the  folds  lie  flatter. 
By  applying  great  firmness  and  long,  steady  strokes  even 
linen  that  is  rough  dried  may  be  made  quite  beautiful. 
A  nurse's  hands  ought  to  be  as  good  as  a  mangle.  All 
these  articles  should  be  laundry  mangled,  but  binders  are 


Fig.  41. 

ironed.  However,  the  laundresses  do  not  fold  for  the 
sterilizing.  The  method  of  folding  should  be  uniform 
throughout  the  hospital.  If  large  sheets  and  blankets 
are  folded  in  and  in,  they  present  a  handsome  appearance, 
since  it  hides  any  dissimilarity  in  stripes,  while  things  of 
varying  sizes  that  have  to  be  used  for  the  same  purpose 
can  be  approximated  to  look  the  same,  but  laparotomy 
sheets  and  gowns  must  be  folded  in  their  assorted  sizes 
to  be  selected  quickly. 

There  should  be  a  large  stock  of  bags  in  the  workroom 


228  OPERATING   ROOM 

for  dressings,  both  sterile  and  unsterile,  ward,  reserve, 
and  operating-room  supplies.  These  may  be  of  stout 
unbleached  muslin,  carefully  stencilled  and  very  fre- 
quently laundered. 

Blankets. — The  top  stretcher  blankets  should  be  crim- 
son, being  much  more  cheerful  and  preventing  any  sight 
of  blood.  They  should  be  of  wool  only,  and  long  enough 
to  reach  from  the  crown  of  the  head  to  the  sole  of  the  foot. 
When  a  nurse  is  preparing  a  stretcher,  if  her  patient  is  very 
tall  she  should  lay  an  extra  blanket  from  the  center  down 
to  have  enough  for  covering  him.  In  every  case  the 
blankets  should  be  laid  on  the  stretcher  first,  then  the 
binder,  then  the  patient,  then  the  lower  blankets  are 
brought  up  over  him  in  every  direction,  particularly  down 
around  the  shoulders  and  up  over  the  feet,  then  new 
blankets  over  all.  It  is  wrong  to  weight  a  patient  down 
with  many  cotton  "blankets?"  because  they  are  worse 
than  useless.  A  couple  of  all  wool  blankets  contain  more 
heat  than  six  cotton  ones;  but  they  should  be  of  a  suit- 
able color,  fawn  or  red,  and  protected  very  carefully  from 
dirt,  so  as  not  to  be  in  the  laundry  all  the  time.  There 
should  always  be  some  kept  in  the  blanket  warmer,  to- 
gether with  gowns  and  stockings.  When  requiring  wash- 
ing they  should  be  first  looked  over  by  the  supervisor  and 
marked  with  a  slip  signed  by  her.  The  laundress  should 
hold  up  all  blankets  not  so  marked.  This  makes  the 
nurses  careful  about  handling  woolen  goods  recklessly. 
Small  woolen  masks,  etc.,  should  be  boiled  to  prevent 
the  spread  of  disease. 

Stains  must  be  removed  before  linen  is  sent  to  be 
washed.  If  so,  the  furtive  attempts  to  use  bleaches  are 
headed  off  and  the  pupils  trained  in  good  housekeeping, 
lodin  is  removed  by  alcohol  or  ammonia.  Rust  on  metal 
is  removed  by  Sapolio,  on  enamel  by  a  weak  solution  of 
oxalic  acid  or  Sapolio,  and  on  white  goods  by  (1)  cream  of 
tartar  paste  and  sunshine  or  (2)  lemon-juice  and  salt. 
Vaselin  and  other  greases  disappear  with  the  application 
of  ether,  but  it  is  very  expensive,  and  the  spots  should  not 


LINEN    OF    THE    OPERATING    ROOM  229 

be  made  in  the  first  place.  Bichlorid  makes  a  gray  stain, 
removable  only  by  Javelle  water  or  Labarraque's  solution, 
the  latter  being  diluted  1  to  6. 

Labarraque's  Solution. — Sodium  carbonate  (washing 
soda),  10  parts;  chlorid  of  lime,  8  parts;  water,  100  parts. 

Linen  for  Isolated  Cases  or  Dirty  Dressings. — Large 
old  linen  ends  can  be  folded  and  sterilized  as  towels  for 
isolation  or  dressings  that  stain.  This  saves  waiting  for 
the  long  period  of  disinfecting.  Do  not  send  good  oper- 
ating-room linen  out  of  the  main  room  for  two  reasons: 
(1)  It  takes  a  long  time  to  get  it  back;  (2)  by  some  mishap 
it  may  not  be  disinfected,  and,  coming  to  that  common 
center,  redistribute  contagion  all  through  the  hospital. 
Small  pieces  should  be  squared  off  and  folded  for  dressings 
for  burns,  for  which  there  is  nothing  better.  Gauze  must 
not  be  put  on  a  burn.  It  allows  the  ointments  to  pass 
through,  then  when  removed  it  tears  off  the  new  granu- 
lations. 

Measures. — A  special  section  must  be  kept  in  the  book 
of  measures  and  patterns  as  to  the  sizes  and  lengths  and 
materials  for  surgeons'  suits,  to  be  sent  to  the  tailoring 
firms  from  whom  they  are  ordered.  No  man  wants  to 
wear  trousers  made  by  the  ladies'  auxiliary.  The  suits 
should  all  come  from  a  well-known  hospital  outfitter, 
thus  saving  time  and  money.  The  addresses  of  firms, 
samples  of  goods,  shrunken  and  unshrunken,  and  the 
cost  must  be  carefully  entered.  It  is  the  head  nurse's 
duty  to  call  the  nurses'  attention  to  all  these  details  in 
regard  to  the  care  of  goods  and  devotion  to  the  needs  of 
the  surgeons;  to  train  them  for  holding  similar  responsible 
positions.  Goods  should  be  ordered  about  twice  a  year 
to  form  a  large  enough  supply  and  to  save  the  payment  of 
too  frequent  freight  bills.  A  strong  plea  is  made  herein 
for  the  nurses'  comfort,  so  as  to  produce  efficiency  and 
content.  Their  gowns  should  be  of  assorted  sizes  and 
with  well-fitting  neck  and  sleeves,,  so  as  to  fit  all  statures. 
A  sloppy  gown  is  not  aseptic. 


CHAPTER  XVII 

BUYING  FOR  THE   OPERATING  ROOM 

Things  not  to  buy  are  most  important  in  a  hospital  or 
private  home.  Nothing  should  be  bought  just  because 
it  is  inexpensive.  It  may  never  be  needed.  Nothing 
should  be  bought  at  the  request  of  only  one  person;  the 
virtues  of  the  article  must  be  demonstrated  to  the  ap- 
proval of  all.  Articles  for  the  operating  room  should  not 
be  out  of  proportion  to  those  of  the  rest  of  the  hospital, 
whether  it  be  ward,  dining-room,  or  laundry,  either  in 
number,  quality,  or  cost.  Glaring  colors,  fads  in  styles, 
and  designs  of  towelling  that  are  not  continuously  uniform, 
so  as  to  be  known  always  instantly  by  sight  as  "0.  R./' 
must  not  be  purchased.  Cheaply  made  goods  have  infe- 
rior dyes,  and  these,  in  turn,  not  being  fast,  ruin  more 
valuable  garments;  for  example,  a  whole  set  of  doctors' 
suits,  trousers,  and  jackets  were  made  pink  by  the  colors 
running  in  some  cheap  new  towels  in  one  metropolitan 
hospital.  All  purchases  should  be  made  by  or  at  the  will 
and  choice  of  the  committee  on  surgical  affairs.  Time 
should  be  taken  by  the  forelock,  and  samples  tried  out 
long  before  the  actual  need  to  purchase. 

These  various  difficulties  can  rarely  be  well  met  by 
one  person.  The  superintendent,  not  actually  engaged 
in  nursing,  does  not  know  how  certain  goods  operate. 
The  operating-room  nurse  knows  where  they  fail,  but 
has  not  time  to  weigh,  count  threads,  meet  several  sales- 
men on  one  class  of  goods,  or  write  for  samples  and  price 
lists.  A  "buyer,"  so-called,  cannot  buy  on  his  own 
first-hand  information.  He  must  collect  statistics  from 
the  house  and  from  his  own  bills  to  satisfy  an  exacting 
superintendent.  In  most  cases  the  buyer  is  so  busy 

230 


BUYING    FOR    THE    OPERATING    ROOM  231 

justifying  his  own  existence  that  he  puts  in  an  inferior 
class  of  goods  or  too  small  a  quantity,  to  the  hampering 
and  unhappiness  of  the  workers.  Then  he  cheerfully 
asks  for  an  increase  of  salary,  to  utilize  the  margin  he 
made,  where  it  can  do  the  greatest  good  to  the  greatest 
possible  number — Number  One. 

.  For  all  hospitals  the  simplest  solution  for  the  problem 
of  buying  is  to  become  a  member  of  that  ingenious  pur- 
chasing body,  reaching  from  America  to  China,  and 
capable  of  buying  anything  from  drinking  straws  to  dicta- 
phones, called  the  Hospital  Bureau  of  Standards  and 
Supplies,  which  is  a  club  consisting  of  representatives 
from  the  largest  and  best  equipped  charitable  institutions 
who  have  joined,  with  a  fair  membership  fee,  to  support 
the  actual  buyers  on  salary,  and  who  can  then  not  only 
secure  goods  at  a  big  discount  from  the  wholesale  firms, 
but  have  no  anxiety  about  selection  or  delivery.  They 
place  their  orders  at  the  head  office  of  the  association, 
whose  buyers  at  once  send  what  they  wish  from  the 
supply  houses  of  the  wholesale  dealers  with  .whom  this 
bureau  has  fixed  yearly  agreements  relating  to  that  kind 
of  goods.  It  is  really  a  very  extensive  mail-order  business. 
But  it  is  not  conducted  for  the  profit  of  one  individual. 
Hospitals  are  not  money  making  concerns.  These  buyers 
must  weigh  all  goods,  taste  all  tea,  coffee,  sugar,  etc., 
count  the  threads  per  inch  in  gauze  or  wool  with  a  magni- 
fying glass  if  necessary,  inspect  cotton  under  the  micro- 
scope, test  the  joints,  valves,  and  bars  in  all  plumbing 
apparatus,  and  only  buy  in  houses  whose  goods  meet  the 
proper  specifications.  Goods  are  delivered  very  quickly 
and  perfect  satisfaction  is  guaranteed.  This  eliminates  at 
least  one  salary  in  institutions  of  some  size,  and  in  the 
small  hospital  releases  the  superintendent  to  attend  to 
the  real  superintending,  of  which  buying  should  not  be 
the  only  duty  performed,  otherwise  certain  basic  prin- 
ciples must  be  observed  in  buying.  Good  goods  produce 
efficiency  in  the  care  of  the  patient,  but  they  must  be 
strictly  accounted  for  in  placing,  number,  length  of  use, 


232  OPERATING   ROOM 

and  suitability.  Buying  a  large  quantity  prevents  ex- 
pense in  freight  and  causes  a  feeling  of  security,  while 
the  goods  are  not  wearing  out.  The  responsibility  of 
caring  for  the  stock  in  bulk  must  be  placed  on  very  few, 
not  only  to  keep  it  in  order,  but  to  distribute  it  weekly. 
Trade  names  have  been  paid  for  twice  over.  "Hexa- 
methylenamin"  is  bought  very  cheaply  and  used  ex- 
actly as  "urotropin"  used  to  be;  "thymol  iodid"  performs 
the  same  duties  as  "aristol,"  but  is  much  cheaper.  But 
a  drug  must  not  be  bought  and  used  this  way  until  it 
responds  to  tests  correctly.  When  buying  certain  articles 
on  requisition  from  the  operating  room  every  feature 
must  be  described — e.  g.,  a  jar  for  saline  infusion  must 
be  graduated  to  750  c.c.,  beginning  at  the  top  with  0  c.c., 
or,  again,  the  length,  style,  material,  eyes,  stylet,  bevelled 
tip  of  lumbar  puncture  needles  must  all  be  specified. 

Whisky  and  brandy  should  be  of  the  best  quality  and 
then  kept  under  lock  and  key,  whether  in  bulk  or  on  the 
wards.  Hospital  whisky,  as  a  rule,  is  a  joke  for  its  uni- 
versal badness,  unfit  for  both  mouth  and  hypodermic 
medication. 

Alcohol  may  be  bought  at  a  very  low  cost  in  its  dena- 
tured state  if  the  proper  forms  are  executed.  The 
president  of  the  Board  of  Governors  must  sign  a  bond 
for  $5000  for  each  barrel  of  alcohol  kept  in  stock  con- 
tinuously by  the  institution  as  a  guarantee  that  its  use  is 
confined  to  surgical,  nursing,  and  pathologic  ends.  Were 
any  one  with  evil  intent  to  drink  or  otherwise  depart  from 
the  legal  uses  of  this  liquid  the  president  would  have  to 
forfeit  this  sum.  An  account,  therefore,  is  kept  of  the 
use  of  all  of  it,  and  the  care  of  it  is  left  to  a  very  con- 
scientious official,  who  keeps  it  well  safeguarded  for  the 
president's  honor.  When  the  liquid  is  being  ordered  an 
affidavit  is  taken  by  the  superintendent  and  president  to 
the  effect  that  its  use  has  been  honest.  For  use  following 
carbolic  acid  as  a  cautery,  however,  alcohol  must  be  used 
in  its  pure,  not  denatured,  state,  on  the  stump  of  the 
appendix. 


BUYING    FOR   THE    OPERATING    ROOM  233 

As  to  catgut,  if  the  committee  on  surgical  affairs  were 
to  visit  and  make  comparisons  of  the  various  plants  or 
laboratories  where  it  is  made  wholesale  they  would  be- 
come impressed  with  the  folly  of  trying  to  do  it  them- 
selves and  the  justness  of  the  prices  imposed.  Possibly 
they  could  also  detect  differences  between  the  materials 
and  preparation  of  these  various  firms  such  as  would 
warrant  the  difference  in  prices;  at  any  rate,  in  these  days 
of  keen  competition,  when  every  manufacturer  knows  the 
secrets,  initial  cost,  and  overhead  expenses  of  his  rivals, 
it  cannot  be  disputed  that  when  there  is  five  cents'  reduc- 
tion in  the  price  there  is  five  cents'  reduction  in  the  value. 
It  is  not  necessary  to  pay  only  for  a  name,  but  when  a 
name  means  confidence  and  merit  it  is  wise  to  procure  the 
best.  Surgeons  who  thoroughly  identify  themselves 
with  the  highest  interests  of  a  hospital  are  economic  of 
catgut.  Their  sutures  are  uniform  for  certain  purposes. 
It  is  then  easy  to  buy  various  lengths  of  catgut,  done  up 
in  separate  tubes  for  various  purposes. 

Emergency  Orders. — In  a  crisis  that  could  not  be  fore- 
seen one  is  justified  in  ordering  by  messenger,  special 
delivery,  parcel  post,  or  express;  but  for  all  that  can  be 
foreseen,  freight  is  suitable  and  cheap,  boat  transporta- 
tion being  again  less  expensive  than  the  railroads. 

Important  supplies  that  concern  the  actual  knack  or 
handicraft  of  a  surgeon  should  be  bought  by  the  com- 
mittee on  instruments  with  grave  deliberation,  not  by 
the  superintendent  of  nurses  or  the  office,  who  have  never 
fitted  them  to  the  hollow  of  their  hand  for  hours  in  the 
greatest  crisis  of  a  patient's  life. 


CHAPTER  XVIII 

MINOR  WORK  IN  THE   OPERATING  ROOM 
OR  BASED   ON  ITS  TECHNIC 

I.     INTRAVENOUS  INFUSION 

INTRAVENOUS  infusions  usually  strike  terror  into  the 
heart  of  a  new  nurse  because  she  attributes  the  shocked 
expression  worn  by  the  staff  on  account  of  the  patient's 
danger  to  some  frightfulness  in  the  treatment  itself. 
Then  she  grows  nervous  and  makes  mistakes.  One  should 
be  glad  that  such  wonderful  results  can  be  accomplished 
by  so  simple  a  thing.  But  the  same  set  of  people  never 
meet  a  second  time  to  give  an  infusion,  and  the  nurse, 
being  the  one  that  "belongs,"  must  know  her  part  thor- 
oughly and  do  her  duty.  When  the  patient  is  in  shock 
from  hemorrhage  or  from  amputation  of  some  organ  or 
limb,  infusion  is  resorted  to  as  a  stimulant,  but  properly 
never  during  a  hemorrhage,  only  after  the  vessels  are 
securely  tied  off  and  the  bleeding  checked.  Normal 
saline,  containing  just  as  much  salt  as  the  blood,  is 
thrown  into  the  vein  to  give  the  heart  enough  fluid  to 
pump  on  until  the  patient  can  manufacture  more  blood. 
It  is  like  the  process  of  priming  a  pump  that  has  gone 
dry,  whose  valves  resemble  those  in  the  heart.  The  infu- 
sion is  given  in  a  vein  to  produce  the  quickest  effect  on 
the  heart,  and  it  is  the  arm  that  is  usually  chosen,  being 
nearest  the  heart.  The  technic  is  universally  the  same, 
though  the  instruments  may  vary  somewhat.  A  tourni- 
quet is  put  on  the  upper  third  of  the  humerus  between 
the  heart  and  the  seat  of  incision.  Nurses  should  get  the 
habit,  when  bathing  patients,  of  observing  the  size,  color, 
and  position  of  the  superficial  vessels.  As  a  rule,  the 

234 


MINOR    WORK    IN    THE    OPERATING    ROOM  235 

median  basilic  vein  is  selected  in  the  left  arm,  since  the 
operator  is  proceeding  with  the  major  work  on  the  right. 
If  for  any  reason  it  is  not  possible  to  use  the  arm,  the 
ankle  is  resorted  to,  where  the  veins  stand  out  promi- 
nently over  the  malleoli.  In  a  patient's  room  either  arm 
may  be  chosen,  depending  on  the  size  of  the  veins.  The 
tourniquet  causes  dilatation  of  the  superficial  vessels, 
but  must  not  be  so  tight  that  it  can  cut  off  the  deeper 
arterial  circulation.  If  the  arterial  supply  were  cut  off 
the  lower  arm  would  be  pale  and  bloodless.  It  is  a  good 
condition,  therefore,  to  find  the  arm  darkened  with  an 
excess  of  venous  blood,  which  cannot  get  back  to  be 
oxygenated  in  the  lungs,  all  the  portion  between  the 
tourniquet  and  the  point  of  incision  being  now  very 
coagulable,  must  bleed  back  before  the  saline  is  injected, 
which,  otherwise,  would  drive  that  thick  impure  mass 
back  toward  the  heart,  possibly  causing  a  plugging  of  the 
circulation  by  a  clot.  Such  a  clot  is  called  a  thrombus, 
and  the  condition  of  being  so  plugged  is  called  thrombosis. 
A  few  snug  turns  of  an  Esmarch  bandage  are  sufficient. 
A  long  rubber  tube  about  as  thick  as  a  rectal  tube,  with 
its  ends  crossed  over  the  vein  and  held'  secure  by  an 
artery  clamp,  makes  a  good  hurry-up  tourniquet.  A 
muslin  bandage  may  suffice. 

The  area  to  be  incised  is  painted  with  iodin  and  sterile 
towels  laid  above  and  below.  The  doctor  performing 
the  infusion  should  wear  cap  and  gown,  since  bad  effects 
may  occur  from  the  dropping  of  dandruff  in  such  a 
wound. 

The  skin  is  incised  about  1  inch  by  a  scalpel.  With 
the  blunt  end  and  a  thumb  forceps  the  sheath  of  the 
vein  is  dissected  away  and  the  swollen  blue  vessel  ex- 
posed. A  grooved  director  is  run  under  it  to  keep  it 
elevated,  then  two  catgut  ligatures,  one  above  and  one 
below  the  coming  incision,  each  tied  loosely  once.  Then 
the  distal  ligature  (measuring  from  the  heart)  is  tied  tightly 
to  prevent  any  more  venous  blood  from  welling  out  into 
the  wound.  All  the  blood  that  previously  travelled  back 


236 


OPERATING    ROOM 


by  way  of  that  vessel  to  the  heart  must  now  forever  take 
one  of  the  side  channels  to  reach  its  destination.  (See 
Anastomosis  in  any  text-book  on  anatomy  in  the  chapter 
on  Circulation  of  the  Blood.)  The  vein  is  now  incised, 
and  by  force  of  gravity  the  thick  dark  mass  above  drips 
back  through  the  canula  (Fig.  42),  now  inserted  to  keep 
the  vein  open,  attached  to  the  fine  rubber  tubing  of  the 
set,  fitting  it  exactly.  The  tourniquet  is  now  removed  and 
a  little  more  blood  allowed  to  drip 
back.  To  the  irrigating  jar  is  joined 
a  sterile  tube  with  a  clip  or  cut-off  and 
a  glass  connecting  tube,  larger  at  one 
end  to  fit  it,  and  smaller  at  the  other 
to  fit  that  tube  which  fits  the  canula. 
The  nurse  releases  the  saline,  and  the 
doctor,  not  depending  on  her  report 
of  the  temperature,  though  not  deny- 
ing it,  lets  some  run  over  his  arm  or 
hand,  then,  all  noting  the  point  at 
which  it  stands  in  the  jar,  the  saline 
is  injected  into  the  vein  by  connecting 
all  the  apparatus.  Irrigators  must  all 
be  graduated.  Some  number  0  at  the 
top,  much  the  better  way.  If  order- 
ing mention  this.  If  50  c.c.  were  run 
off  before,  the  patient  begins  to  receive 
any,  and  at  750  c.c.  we  stop  because 
he  shows  sufficient  reaction,  he  re- 
ceived only  750  —  50  c.c.  or  700  c.c.  It  is 
also  better  to  graduate  in  cubic  centimeters,  since  the  small 
amounts  can  be  meticulously  gauged.  Some  jars  are 
built  like  a  bottle  with  a  spout  at  the  bottom;  others  are 
a  modified  inverted  cone,  tapering  to  fit  the  lumen  of  an 
ordinary  tube.  These  give  general  satisfaction,  and  it  is 
useless  to  cover  them  at  the  top.  They  give  a  very  steady 
flow  on  account  of  the  generous  surface,  and  the  speed 
can  be  controlled  below  by  slight  pressure  on  the  tube  to 
prevent  dilatation  of  the  heart.  The  temptation  always 


Fig.  42. — Infusion 
canula  with  stop- 
cock (Bellevue  Hos- 
pital) . 


MINOR    WORK    IN    THE    OPERATING    ROOM 


237 


Fig.  43. — Potain's    aspirator,    60    c.c. — metal    barrel    and    metal 
piston,  three  needles,  one  stop-cock,  one  trocar,  and  tubing. 


Fig.  44.— Bottle  for  Potain's  aspirator,  500  c.c. 


238  OPERATING    ROOM 

is  to  hurry.  That  is  a  mistake.  The  only  cause  for  hurry 
is  the  patient's  bad  condition  or  the  cooling  of  the  saline. 
The  temperature  of  the  solution  is  a  mooted  one.  It  is 
usually  started  at  120°  F.  to  allow  for  slow  delivery, 
cooling  while  in  the  long  tube;  but  it  must  be  delivered  at 
98.6°  to  100°  F.,  practically  at  body  heat,  not  cooler; 
therefore  we  need  two  thermometers,  one  to  test  the 
solution  in  the  tank  and  one  to  test  it  just  before  it  enters 
the  vein.  A  bath  thermometer,  stripped  of  its  wooden 
casing  and  kept  in  an  antiseptic  solution,  then  rinsed  in 
sterile  water  and  held  by  forceps,  may  be  used  above. 
An  "infusion  thermometer"  consists  of  a  large  glass 
connecting  tube  with  a  thermometer  placed  stationary 
inside  of  it.  It  is  of  equal  lumen  at  the  ends,  and  we 
simply  cut  the  long  tube  from  the  jar  and  slip  it  in  near 
the  lower  end.  It  registers  from  90°  to  104°  F.,  and  it  is 
imperative  to  have  it  in  all  hypodermoclysis,  infusion, 
and  Murphy  drip  sets.  If  the  solution  runs  too  cool,  a 
small  amount  of  hotter  saline  is  cautiously  added,  watch- 
ing the  upper  thermometer;  about  1  ounce  at  a  time, 
since  it  goes  slowly  down  the  tube,  but  runs  up  the 
mercury  fast  when  it  gets  there.  Cool  should  be  added 
similarly  when  the  other  is  too  hot.  The  tube  should  be 
pinched  low  down  until  these  temperatures  are  adjusted. 
Hurry  and  excitement  are  sinful  at  such  a  time,  and  are 
not  any  excuse  for  administering  too  cold  or  too  hot  a 
solution.  The  amounts  added  must  be  kept  in  mind. 
If  all  is  going  well,  and  the  patient  will  take  more  than  the 
jar  holds,  a  new  amount  of  the  right  temperature  is  carried 
in  a  sterile  pitcher  and  poured  in  without  touching  the 
latter  to  the  jar  and  covered  with  a  sterile  towel  while 
carrying.  When  about  to  pour  it  in  the  long  tube  is 
pinched  below  the  infusion  thermometer,  and  the  amount 
in  the  jar  noted.  Say  it  stands  at  740  c.c.  When  we  know 
more  will  be  needed,  it  must  be  added  before  the  old 
solution  gets  below  the  lowest  mark — (a)  so  that  we  can 
estimate  it;  (6)  so  that  no  air  will  get  into  the  vein.  When 
filling  any  glass  container  for  the  first  time  cool  liquids 


MINOR    WORK    IN    THE    OPERATING    ROOM  239 

should  be  poured  in  first,  then  the  hot  is  so  tempered  that 
it  cannot  break  the  glass.  If  then  we  fill  it  up  to  0  c.c., 
we  have  added  740  c.c.  If  it  was  standing  at  750  c.c. 
when  we  stopped,  and  we  filled  it  to  150  c.c.,  then  we 
added  only  750  —  150  c.c.  =  600  c.c.  to  the  original 
amount. 

The  bottom  of  the  irrigating  jar  should  not  be  more  than 
one  foot  above  the  patient's  body,  and  everyone  else  con- 
cerned must  be  patient,  too,  while  it  runs  evenly.  The 
sterile  tape  boiled  with  the  jar  hangs  it  to  the  stand. 
The  towels,  iodin,  and  set  should  be  brought  first,  so  that 
by  the  time  the  incision  is  made  the  jar  of  saline  is  in 
position.  The  patient's  pulse,  respiration,  color,  finger- 
tips, skin,  and  other  features  must  be  closely  scrutinized, 
and  when  they  are  all  again  normal  the  treatment  is 
stopped.  The  proximal  ligature  has  already  one  loose 
knot,  in  it,  which  is  now  tightened  over  the  canula,  which 
is  withdrawn,  and  the  saline  cut  off,  then  the  ligature  is 
tightened,  knotted,  and  the  wound  sponged  out.  A 
couple  of  sutures  with  a  straight  or  curved  Hagedorn 
needle  close  the  wound  with  plain  catgut.  It  is  dusted 
with  aristol,  covered  with  folded  gauze,  and  snugly  ban- 
daged with  gauze,  not  so  as  to  interfere  with  the  movement 
of  the  arm.  Mouse-tooth  forceps  must  not  be  used  on  the 
vein.  The  artery  clamp  of  the  set  will  stop  any  small 
bleeders.  The  probe  may  help  in  locating  the  vein. 

It  is  most  expedient  to  make  saline  up  in  triple  strength, 
that  is,  3  drams  to  1  pint,  for  this  very  purpose,  so  that 
the  very  hot  may  be  diluted  by  twice  the  amount  of  cold 
sterile  water.  To  make  it  triple  strength  saves  space  and 
time,  but  it  must  be  marked  so,  and  everyone  must  have 
that  understanding  also.  Nurses  from  the  wards  rush- 
ing up  for  supplies  should  not  help  themselves.  Saline 
is  given  out  by  a  reliable  member  of  the  pupil  staff.  At 
night,  when  all  supplies  are  locked  away,  only  the  night 
supervisor  or  some  pupil  who  "has  had  operating-room" 
should  have  access  to  the  stock,  leaving  a  note  on  the 
spindle  saying  where  it  went  and  what  its  use. 


240  OPERATING   BOOM 

Infusion  Set. 

Irrigating  jar  with  tubing  and  tape. 

Cut-off. 

Dairy  thermometer. 

Infusion  thermometer. 

Glass  connecting  tube. 

Canula  (silver  only). 

Fine  rubber  tubing  (never  cut  a  catheter). 

Scalpel  with  free  curved  edge. 

Thumb  forceps. 

Mouse-tooth  forceps. 

Artery  clamp. 

Probe. 

Grooved  director. 

Curved  scissors. 

Hagedorn  needle,  curved  or  straight. 

Plain  catgut  No.  1. 

Infusion  stand. 

Table  for  the  arm. 

Sterile  towels. 

Flat  gauze  and  sponges. 

Bandage,  2-inch  gauze. 

Tourniquet. 

Aristol. 

Saline  flasks,  asbestos  mat. 

Hot  and  cold  water  (pitcher). 

lodin,  2.5  per  cent.  (J  tincture,  f  pure  alcohol). 

Sponge  pail. 

To  Put  Up  the  Infusion  Set.— The  set  should  be  kept  in 
readiness  in  sterile  covers  on  a  tray  inside  a  locked  cup- 
board. It  should  be  opened  at  regular  intervals  to  see 
that  everything  is  in  it  and  rustless,  then  resterilized. 
The  very  best  of  instruments  should  be  used.  Wash  after 
using,  scrub  with  Bon  Ami,  and  boil  the  irrigator,  three 
tubes,  cut-off,  canula,  scissors,  clamp,  forceps,  probe, 
grooved  director,  needles,  glass  connecting  tube,  but  soak 
in  bichlorid  (1  :  1000)  the  catgut  and  two  thermometers, 
and  in  carbolic  acid  and  alcohol  the  scalpel.  Lift  the  tray 


MINOR    WORK    IN    THE    OPERATING    ROOM  241 

out  of  the  boiler  to  drain  the  boiled  articles,  dry,  and 
handle  them  with  sterile  forceps.  On  a  clean  table  lay 
sterile  towels  as  a  cover.  Above  these  lay  sterile  towels 
folded  double  laterally  to  be  used  to  put  up  the  articles. 
Keeping  the  hands  under  another  sterile  towel,  and  lifting- 
each  article  by  a  forceps,  wipe  it  thoroughly  dry  and  lay 
it  in  its  towel  cover.  Similarly  do  with  the  catgut  knife 
and  thermometers,  rinsing  them  under  the  sterile  water 
tap.  In  one  package  place  the  irrigator  with  its  tape  and 
cut-off,  two  pieces  of  large  tubing,  dairy  and  infusion 
thermometers,  so  that  if  need  be  it  may  be  used  to  give  a 
hypodermoclysis.  For  this  purpose  we  do  up  separately 
after  that  treatment  a  glass  Y,  two  fine  pieces  of  tubing, 
and  the  hypodermoclysis  needles  (a  pair  with  stylets), 
sterile  or  simply  clean  and  ready  for  boiling,  because  they 
can  be  easily  boiled  in  time.  Each  package  should  be 
fastened  securely  with  buried  pins  and  labelled  with  ad- 
hesive or  gummed  labels.  The  nurse  who  does  them  up 
should  write  her  name  on  the  outside  of  the  package. 
Dry  sterilization  is  not  so  dry  that  it  is  good  for  instru- 
ments. It  rusts  them.  These  bundles  must  always  be 
kept  in  the  same  place. 

In  the  second  package  put  the  canula,  scissors,  clamp, 
mouse-tooth  and  thumb  forceps,  probe,  grooved  director, 
glass  connecting  tube,  fine  rubber  tubing,  scalpel,  needles, 
and  catgut,  which  may  be  used  also  for  phlebotomy. 

Infusions  must  not  go  wrong.  Hospitals  have  disgrace- 
ful traditions  about  infusion  sets,  aspirators,  and  cauter- 
ies, so  that  it  has  come  about  that  the  doctors  are  sur- 
prised if  they  go  well.  Any  tiny  hospital  should  have  at 
the  very  least  two  infusion  sets  complete — (a)  in  case  two 
patients  need  it  at  once;  (b)  in  case  parts  of  a  set  are  lost 
or  are  being  renickelled;  (c)  in  case  a  patient  requiring  it 
is  in  isolation.  A  list  of  what  belongs  to  any  set  should 
be  found  in  the  house-book  of  rules  and  pasted  on  the  tray 
where  the  set  is  kept. 


242  OPERATING   ROOM 

H.     HYPODERMOCLYSIS 

For  all  these  treatments  put  the  bedside  table  near  the 
foot  of  the  bed,  but  on  the  right-hand  side. 

Required : 

(a)  Two  needles  with  stylets,  all  in  good  condition 
(dried  over  an  alcohol  flame,  then  lubricated,  assorted 
sizes);  2  pieces  of  fine  rubber  tubing  to  fit  them;  1  glass  Y. 
(Kept  together  at  all  times.) 

(6)  One  sponge-holder  (from  the  ward)  for  iodin. 

(c)  Jar  or  irrigator  for  saline  with  tape  loop;  long  rub- 
ber tube  containing  infusion  thermometer;  cut-off;  dairy 
thermometer.     (Kept  in  one  set  as  for  infusion.) 

(d)  Stand,    collodion,   iodin   in   2-ounce   glass,   towels, 
cotton,  pus  basin,  sponge  pail  (on  floor),  sponges. 

The  saline  is  prepared  as  for  infusion.  If  triple  strength, 
it  is  diluted  with  hot  and  cold  sterile  water.  The  hot 
flasks,  if  normal,  must  not  be  set  on  a  glass  table  without  a 
thick  covering,  to  prevent  cracking  the  table. 

Set  the  table  with  sterile  towels  lifted  out  of  their  cover 
by  the  ward  forceps  (in  lysol).  Lift  the  boiled  articles  of 
(a)  out  of  their  basin  at  the  bedside  and  lay  on  the  towels. 
Lift  out  the  thermometer,  sponges,  cotton,  etc.,  and 
hang  up  the  jar,  holding  the  end  of  the  tube  with  forceps 
on  the  table  so  that  it  will  not  become  unsterile.  Place 
the  iodin  at  one  edge  so  that  it  will  not  be  in  the  way  after 
the  start  is  made  or  contaminate  the  rest.  Place  the 
sponge  pail  and  pus  basin  so  as  to  catch  the  overflow 
while  the  needles  may  be  adjusted.  When  pouring  into 
the  irrigator  do  not  touch  the  two  containers  together. 
Pour  a  little  cold  solution  first  always,  so  as  to  prevent  the 
hot  from  cracking  the  glass.  While  the  doctor,  who  has 
scrubbed  up,  is  fitting  the  needles,  withdrawing  the 
stylets  that  are  always  to  be  boiled  in  them,  adjusting  the 
glass  Y  and  the  tubing,  the  nurse  prepares  the  patient. 
The  arms  are  placed  above  the  head,  the  gown  drawn  up 
to  the  chin  and  tucked  tightly  under  the  shoulders,  the 
face  shaded  by  a  towel  if  conscious,  and  sterile  towels  laid 
across  the  chest  and  abdomen  above  and  below  the  nipples 


MINOR    WORK    IN    THE    OPERATING    ROOM  243 

(breasts).  The  doctor  applies  iodin  to  both  surfaces  of 
injection  (the  base  of  the  breasts)  with  sponge  on  holder. 
The  nurse  operates  the  cut-off  so  that  the  solution  runs 
until  the  temperature  below  is  100°  to  102°  F.,  then  the 
cut-off  is  tightened  and  the  needles  inserted  while  stand- 
ing full.  Then  the  cut-off  is  opened,  and  the  doctor  gently 
massages  the  solution  back  into  the  farther  tissues  and 
watches  the  temperature,  the  patient's  appearance,  etc. 
The  nurse  notes  the  amounts,  as  in  infusion,  replenishes 
it  when  it  runs  low,  and  tests  the  temperature  above,  also 
taking  the  patient's  pulse  from  time  to  time.  One  wound 
is  dressed  with  collodion  on  cotton  before  withdrawing  the 
second  needle,  so  that  none  runs  out  due  to  internal  pres- 
sure. Usually  the  amount  is  ,1000  to  1500  c.c.  That 
can  be  very  well  borne.  The  patient  is  then  made  com- 
fortable and  all  things  cleared  away. 

These  articles  must  be  immediately  washed,  boiled, 
and  sent  to  the  operating  room  for  final  sterilization. 
Even  when  that  process  is  only  boiling,  putting  up  these 
packages  must  be  done  by  an  operating-room  nurse,  and 
she  must  see  that  the  ward  returned  everything  O.  K. 

Irrigating  jars  look  very  clean  if  dry  sterilized,  but,  on 
the  other  hand,  that  rots  their  tubing.  If  boiled  in  a 
towel  no  scum  should  adhere. 

Use  small  needles  for  children. 

INJECTION   OF  BLOOD-SERUM 

In  certain  conditions  of  (1)  hemorrhages  of  the  new- 
born, (2)  traumatic  hemorrhages,  (3)  hemorrhages  after 
operations,  and  (4)  purpura  hemorrhagica  (early)  the 
loss  to  the  general  circulation  is  sometimes  restored  by  the 
injection  of  blood-serum.  As  in  transfusion,  the  blood 
of  a  very  near  relative  by  consanguinity — that  is,  one's 
own  parent  or  a  descendant  of  the  same  parents  as  one's 
self — must  be  obtained.  For  a  newborn  infant  the  father, 
and  for  a  newly  delivered  woman  her  father,  mother, 
brother,  or  sister.  The  blood  from  the  donor  is  with- 
drawn, set  in  the  ice-box  in  a  sterile  open-mouthed  vessel, 


244  OPERATING   ROOM 

but  covered,  to  permit  taking  out  the  clots  easily  after 
they  form,  yet  let  nothing  unclean  drop  in.  In  twenty- 
four  hours,  when  the  coagulable  matter  has  collected  into 
one  clot,  the  serum,  now  absolutely  clear  and  slightly 
heated  to  body  temperature  by  standing  in  tepid  water, 
is  injected  by  a  large  ground-glass  syringe  in  doses  of 
15  to  25  c.c.  in  the  patient's  buttocks.  As  a  rule,  the 
second  treatment  is  the  last.  In  all  these  cases  the  donor 
shows  marked  effects :  (a)  Bluish  patches  under  the  eyes, 
which  are  sunken;  (6)  general  lassitude;  (c)  great  disturb- 
ance of  the  heat  centers,  heat  sensations  rapidly  and 
irregularly  alternating  with  cold,  showing  that  he  must  be 
put  to  bed  until  his  circulation  is  readjusted.  The  injec- 
tion is  performed  with  strict  asepsis. 

TRANSFUSION 

Transfusion  means  transferring  blood  directly  and 
while  yet  warm  from  the  body  of  a  healthy  donor  to  the 
body  of  a  patient.  It  must  be  distinguished  from  infusion 
in  these  ways: 

(a)  In  infusion  the  fluid  is  saline. 

(6)  In  infusion  there  is  only  one  person  treated. 

(c)  In  infusion  there  are  no  tests  for  coagulation,  etc., 
required.  It  is  indicated,  according  to  the  best  authors, 
in  the  following  cases:  gastric  and  duodenal  ulcer,  typhoid, 
ectopic  pregnancy,  tonsillectomy  followed  by  hemorrhage, 
purpura  hemorrhagica  (advanced),  hemophilia,  carbon 
monoxid  poisoning. 

The  blood  must  be  tested  by  a  skilled  pathologist  to  de- 
termine the  degree  of  agglutination,  which  should  corre- 
spond in  the  donor  and  the  patient.  The  donor  should 
preferably  be  a  blood  relation,  that  is,  the  father,  mother, 
uncle,  sister,  brother,  son,  or  daughter  of  the  patient.  If 
the  blood  of  a  cat  were  injected  into  a  human  being  the 
latter  would  possibly  die  after  the  first  and  positively  after 
the  second  injection.  Vice  versa,  if  a  man's  blood  were 
injected  into  a  cat,  the  latter  would  die  of  blood  destruc- 
tion or  hemolysis. 


MINOR   WORK   IN   THE    OPERATING    ROOM  245 

The  strictest  asepsis  is  required.  The  two  persons  lie 
parallel  on  two  operating-tables  of  equal  height.  The  right 
arm  of  the  patient  and  the  left  arm  of  the  donor,  or  vice 
versa,  are  cleansed  and  then  wrapped  in  sterile  towels,  laid 
on  a  table  of  the  same  height,  midway  between.  At  the 
foot  stands  a  similar  table  for  the  "scrubbed  nurse,"  who, 
during  the  operation,  constantly  washes  the  syringes  in 
water  at  about  100°  F.  If  upon  careful  inspection  it  is 
found  impossible  to  use  the  median  basilic  vein,  a  more 
extended  search  is  made  for  suitable  vessels,  which  will 
necessitate  a  different  placing  of  the  persons. 

The  operator  punctures  the  patient's  arm  with  the 
common  salvarsan  needle,  lubricated  inside  with  sterile 
liquid  albolene,  then  the  donor's  arm  with  a  second. 
The  venous  blood  ascends  the  arm  and  the  needle  taps  an 
ascending  stream,  but  the  blood,  flowing  back,  bleeds  only 
a  little,  and  it  is  merely  sufficient  to  fill  the  needle  and  ex- 
pel all  air  before  the  syringe  is  fitted  on. 

On  the  arm  of  the  donor  the  first  syringe  is  filled. 
These  are  20  c.c.  in  content,  of  ground  glass,  the  best  to 
be  had,  working  beautifully.  About  six  syringes  should 
be  kept  constantly  on  the  go  to  expedite  the  process. 
Being  reasonably  healthy  and  at  least  mildly  excited,  the 
donor  has  an  increased  blood-pressure  which  may  fill  the 
syringe  by  pushing  back  the  piston  without  aspiration. 

The  operator  lays  down  the  full  syringe,  swiftly  raises 
another,  and  lets  it  fill.  The  moment  he  relinquishes  one 
full  syringe  the  assistant  fits  it  to  the  needle  in  the  pa- 
tient's arm,  injecting  all  but  about  J  dram,  which  he  ex- 
pels to  show  that  he  did  not  drive  air  into  the  vein.  A 
nurse  keeps  count  of  the  number  of  syringes  filled.  The 
operation  never  ceases  until  enough  is  injected  to  meet 
the  demands — 1  pint,  or  twenty-five  20-c.c.  syringes,  can 
be  injected  in  nine  minutes. 

Another  assistant  is  required  to  pass  the  syringes  to 
and  from  the  nurse  continuously. 

The  needles  are  withdrawn  and  the  slight  wounds 
dressed  with  cotton  and  collodion.  There  are  no  incisions, 


246  OPERATING   ROOM 

no  scalpels,  no  great  chances  for  infection.  The  patient's 
color,  lips,  nails,  pulse,  and  respiration  should  be  very 
closely  watched  during  this  delicate  but  brilliantly  showy 
performance. 

PHLEBOTOMY,  VENESECTION,  BLOOD-LETTING 

The  doctor  used  to  be  called  "the  leech"  at  a  time 
when  all  disease  was  supposed  to  be  due  to  having  too 
much  blood,  and  living  leeches  sucked  out  the  overplus. 
Later  the  physician  used  a  scalpel  and  saw  how  much  he 
"let."  But  phlebotomy  is  now  rather  rare,  and  only  in 
conjunction  with  an  accurate  diagnosis  made  by  the  assist- 
ance of  a  sphygmomanometer.  In  the  "open"  method  a 
wound  is  made  and  the  vessel  then  tied  off  twice,  as  in 
intravenous  infusion.  Required: 

(1)  The  instruments  of  the  infusion  set,  scalpel,  forceps, 
catgut,  etc. 

(2)  Pus  basin  to  catch  the  flow  of  blood,  graduate  to 
determine  the  amount,  and  pail. 

(3)  Large  rubber  to  protect  the  bed,   sterile  towels, 
sponges,  etc. 

Set  the  table  as  for  infusion.  Do  not  let  the  patient 
see  the  red  stains  and  cause  him  needless  alarm.  Watch 
the  force  of  his  pulse-beat.  Do  not  allow  any  blood- 
stream to  escape  unnoticed  and  uncalculated,  thereby  de- 
pleting the  patient  too  greatly. 

In  the  "closed"  method,  to  obtain  only  a  very  small 
amount,  as  for  blood  cultures,  which  must  be  conducted 
in  an  aseptic  manner,  a  needle  is  employed  to  puncture 
the  vein,  but  there  is  a  special  technic  arranged  by  pathol- 
ogists  for  cleansing  the  skin,  disinfecting  instruments  and 
containers,  etc.,  which  should  be  posted  in  each  hospital 
and  arranged  for  by  the  ward  nurses  to  suit  his  conve- 
nience. His  desire  for  asepsis  is  to  prevent  any  outside 
germs  from  entering  the  blood,  lest  he  attribute  them  to  the 
patient  himself.  Our  desire  for  asepsis  is  to  prevent  any 
bacteria  from  getting  into  the  patient. 


MINOR    WORK    IN    THE    OPERATING    ROOM  247 

LUMBAR  PUNCTURE 

This  is  employed  as  a  test  for  cerebrospinal  and  tuber- 
cular meningitis,  and  must  be  conducted  with  most  aseptic 
precautions  for  two  reasons:  (a)  Not  to  infect  the  patient; 
(b)  to  see  his  spinal  fluid  as  it  really  is. 

Required : 

(1)  lodin,    cotton,    collodion,    sterile    2-ounce    glass, 
forceps. 

(2)  Lumbar  puncture  needles,   assorted  sizes,   special 
design,  with  bevelled  stylet  and  an  eye  J  inch  above  the 
point. 

(3)  Sterile  glass  graduate  to  contain  the  first  flow  of 
fluid  (small). 

(4)  Sterile  glass  graduate  to  send  whole  amount  to  the 
laboratory,  if  necessary,   and  to  estimate  it,   this  fluid 
being   sought   by   the   big   laboratories   to   manufacture 
from  it  antimeningitic  serum. 

(5)  Rubber  sheet,  towels,  pus  basin,  sponges,  etc. 
The  patient's  knees  and  chin  are  brought  together  so 

as  to  bow  out  the  lumbar  vertebrae.  The  area  is  painted 
with  iodin,  then,  the  landmarks  being  carefully  taken, 
the  needle  is  inserted,  the  smallest  glass  held  beneath  it, 
and  the  stylet  withdrawn.  Ethyl  chlorid  destroys  the 
landmarks  by  freezing. 

To  inject  antimeningitic  serum,  required: 

(1)  The  serum,  standing  in  a  tepid  solution  of  bichlorid 
of  mercury,  1  :  3000,  at  a  temperature  of  100°  F.     It  must 
be  allowed  to  run  in  at  body  temperature  in  such  a  vital 
spot. 

(2)  Special  glass  and  tube,   as  for  spinal  anesthesia. 
This  glass  is  like  the  outside  of  a  large  glass  syringe,  open 
at  both  ends,  the  lower  tapering  and  the  whole  graduated. 
It  contains  20  c.c.  and  fits  a  fine  piece  of  rubber  tubing 
which,  in  turn,  fits  the  needle.     No  air  is  allowed  to  enter 
and  no  force  is  employed.     The  cord  is  not  aspirated, 
just  tapped — i.  e.,  the  fluid  is  let  run  out  by  gravity. 
Similarly  it  is -let  run  in  by  gravity,  never  propelled  by  a 


248  OPERATING   ROOM 

piston.  If  the  serum  were  used  cold  it  would  cause  a 
subnormal  temperature  and  additional  discomfort  to  the 
patient. 

SPINAL  ANESTHESIA 

Spinal  anesthesia  is  an  exact  duplicate  of  the  above, 
except  that  the  fluid  introduced  (without  any  force)  is  a 
chemical  substance,  innocuous  to  heart  and  kidneys  in 
the  normal  individual,  while  chloroform  is  injurious  to 
the  one  and  ether  to  the  other. 

In  addition  to  the  articles  above  named  is  found  a  small 
sterile  glass,  into  which  the  ampoules  of  stovain  are  first 
broken  and  whence  it  is  poured  into  the  special  graduated 
tube  for  introduction  into  the  cord. 

The  patient  is  stripped  to  the  waist  of  his  loose  operat- 
ing-room garb,  and  sits  on  the  operating-table  in  the  main 
room,  leaning  forward  with  his  arms  over  the  shoulders 
of  a  shorter  person  standing  close  to  him  so  as  to  bow  out 
his  back  at  the  lumbar  region.  The  area  is  cleansed  with 
iodin  and  alcohol,  then  the  spinal  fluid  is  drawn  off.  It 
is  not  required  for  examination  or  measurement.  The 
tube  for  stovain  is  connected  and  held  very  low,  to  show 
the  presence  of  spinal  fluid,  to  which  the  stovain  is  now 
added,  so  as  not  to  introduce  any  air,  then  raised  to  a 
normal  position.  The  patient's  arms  are  drawn  above 
the  head  and  the  eyes  covered.  Then  his  sensation  is 
tested,  from  the  toes  up  to  the  point  selected  for  the 
wound.  When  complete  anesthesia  up  to  the  desired 
point  is  obtained,  he  is  laid  on  the  table  and  the  opera- 
tion begun.  Some  patients  have  died  following  this 
anesthetic  and  others  have  died  from  the  effects  of  the 
operation,  while  it  has  for  still  others  been  ideal. 

ARTIFICIAL  RESPIRATION 

This  is  positively  the  duty  of  the  physician,  but  in  case 
he  is  not  to  be  found,  or  has  been  incapacitated  in  any  way, 
a  nurse  should  know  how  to  perform  it,  just  as  it  is  done 
by  the  Life  Saving  Corps  or  by  gymnasium  instructors. 


MINOR    WORK    IN    THE    OPERATING    ROOM  249 

The  Sylvester  method  is  very  satisfactory  because  it 
can  be  comprehended  by  others  than  physicians. 
General  Rules: 

I.  Never  give  up  hope;  keep  up  the  treatment  for  at 
least  ninety  minutes. 

II.  Consider  the  patient  alive  at  the  start. 

III.  Carry  out  the  treatment  where  the  patient  is. 

IV.  See  that  there  is  no  obstruction  in  the  nose  or 
throat. 

V.  Do  not  get  excited  and  do  not  give  too  rapidly. 

VI.  Elevate  the  patient's  shoulders  about  4  inches. 

VII.  Clamp    the    tongue,    and    let    another    assistant 
draw  it  forward  with  each  expiration,  and  not  let  it  drop 
back,  ever  so  slightly,  with  each  inspiration,  impeding  it. 

VIII.  Stand  or  kneel  far  enough  above  the  patient  to 
have   good   purchase   when   pressing   downward   behind 
his  head. 

IX.  Make  the  (inward  and  outward)  respirations  for 
an  adult  16  to  the  minute — that  is,  3f  seconds  each- 
two  seconds  for  the  inspiration  and  almost  two  seconds  for 
the  expiration. 

X.  (a)  Grasp  him  by  the  forearms,  half-way  between 
elbows  and  wrists,  and  draw  up  his  arms  out  and  over  his 
head  steadily  until  the  hands  touch  the  table,  floor,  or 
ground  behind  his  head.     Hold  them  there  for  two  sec- 
onds.    This  motion  expands  the  chest  by  drawing  up  the 
ribs;  air  may  enter.     Two  seconds'  halt  allows  it  plenty 
of  time  to  fill  the  lungs  completely.     (6)  Reverse  that 
movement.     Carry  the  arms  downward  until  they  rest 
against  the  sides  of  the  chest,  bringing  the  forearms  in  a 
little  on  top,  pressing  them  firmly  downward  and  inward 
against  the  chest  for  one  second.     Listen  for  the  sound  of 
air  entering  and  leaving.     If  not  heard,  the  work  has  been 
done  incorrectly. 


CHAPTER  XIX 

PREPARATIONS  BY  THE  NURSE  IN 
ORTHOPEDIC   SURGERY 

OPEN  work  on  bones  requires  the  most  assiduous 
efforts  at  asepsis,  but  this  has  been  discussed  briefly 
elsewhere.  Closed  operations,  or  the  breaking,  straight- 
ening, and  overcorrection  of  bone,  show  no  open  wound. 
But  poor  or  improperly  prepared  materials  hamper  the 
orthopedic  surgeon  very  greatly,  much  more  than  the 
dressings  for  a  laparotomy  could  do,  if  clumsy  or  un- 
familiar. Plaster  work  requires  in  a  surgeon  a  natural 
aptitude  or  knack,  but  the  most  wonderful  knack  cannot 
make  a  good  cast  out  of  poor  crinoline,  inferior  plaster,  or 
badly  soaked  bandages.  Making  plaster  bandages  is  a 
regular  part  of  the  operating-room  training,  and  must  not 
be  relegated  to  an  orderly. 

Definitions. — Surgical  Diagnosis. — For  deformities  cer- 
tain technical  terms  are  used: 

Congenital  dislocation  of  the  hip.  A  deformity  existing 
from  birth,  the  head  of  the  femur  being  lodged  outside  the 
acetabulum,  with  the  formation  of  powerful  adhesions. 
Frequently  this  occurs  in  both  sides. 

Funnel  breast.  A  depression  of  the  chest  walls  at  the 
sternum  resembling  the  bowl  of  a  funnel.  It  is  like  a 
shoemaker's  chest,  only  it  may  occur  at  any  point.  It 
is  corrected  by  very  strenuous  exercises,  not  by  operation, 
but  must  be  done  early  to  abort  any  hereditary  predis- 
position to  tuberculosis  by  increasing  the  child's  lung 
capacity. 

Genu  valgum.  Inward  curving  of  the  knee,  knock- 
knee,  opposite  of  bow-legs. 

Genu  varum.  Splay  foot;  synonym  of  talipes  valgus, 
bow-legged;  inner  part  of  the  sole  rests  on  the  ground. 

250 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  251 

The  preceding  are  neuter  nouns  and  adjectives,  there- 
fore the  latter  end  in  um. 

Hallux  valgus.  Displacement  of  the  great  toe  toward 
the  other  toes. 

Hallux  varus.  Disposal  of  the  great  toe  away  from  the 
other  toes — displacement. 

These  are  masculine,  therefore  ending  in  us. 

Hip  disease.  Usually  tuberculous  and  in  the  young. 
It  lodges  in  the  head  of  the  femur,  in  the  acetabulum,  or 
in  the  synovial  membrane  and  proper  structures  of  the 
hip-joint.  The  early  symptoms  are  shuffling  gait,  pain 


Fig.  45. — Osteoclast  (Phelps'  modification  of  Grattan's). 

on  the  inner  side  of  the  knee,  pain  in  the  hip  on  jarring  the 
heel,  deformity,  shortening  of  the  limb,  suppuration,  and 
formation  of  fistulse. 

Kyphosis.  Angular  curvature  of  the  spine,  the  promi- 
nence extending  posteriorly. 

Lordosis.  Curvature  such  that  the  convexity  points 
forward. 

Osteoclast.  Instrument  to  break  bones  to  correct  de- 
formity (Fig.  45).  Do  not  confuse  with  the  term  "osteo- 
blast,"  which  means  a  cell  found  in  the  formation  of  bony 
tissue  in  the  embryo. 


252  OPERATING   BOOM 

Pott's  disease.  Curvature  of  the  spine  with  a  poste- 
rior projection  due  to  spondylitis  or  inflammation  of  a 
vertebra.  It  is  usually  tuberculous.  It  may  be  high 
or  low.  When  high,  it  is  more  quickly  discoverable; 
when  low,  it  shows  up  usually  as  a  psoas  abscess,  the  in- 
flamed area  breaking  down  into  pus  which  migrates  down- 
ward along  certain  muscles  toward  the  inguinal  region. 
The  symptoms  of  Potts'  disease  are  stiffness  of  the  spinal 
column,  pain  on  motion,  tenderness  on  pressure,  undue 
prominence  of  one  or  more  spines,  and  a  particularly 
wistful  facial  expression. 

Scoliosis.  Lateral  curvature  of  the  spine,  bending  of 
the  column  to  right  or  left. 

Talipes.     Club-foot. 

Talipes  equinus.  The  heel  is  elevated,  and  the  weight 
is  all  thrown  on  the  anterior  portion  of  the  foot,  like  a 
horse's  foot. 

Talipes  planus.     Flat-foot. 

Talipes  valgus.     Foot  turned  outward. 

Talipes  varus.     Foot  turned  inward. 

APPARATUS 

A  Bradford  frame  may  have  to  be  constructed  quickly 
to  provide  horizontal  fixation  in  cases  of  children  suffering 
from  fractures  or  from  tuberculosis  of  the  spine.  The 
frame  itself  is  of  bent  gas-piping,  from  f  to  J  inch  thick,  in 
a  perfect  oblong,  1  inch  wider  than  the  patient's  body  at 
his  hips,  and  6  inches  longer  than  his  full  stature;  that  is, 
in  the  proportion  of  about  1  to  5.  It  is  covered  by  a 
piece  of  stout  canvas  twice  its  width,  and  laced  down  the 
back  on  the  center  of  the  side  away  from  the  child  with 
eyelets  and  stout  laces.  It  is  arranged  to  leave  an  open- 
ing for  the  bed-pan,  which,  however,  does  not  interfere 
with  the  tautness  longitudinally,  which  is  taken  care  of 
by  two  pairs  of  webbing  straps  at  the  head,  and  again 
at  the  foot.  This  frame  is  constructed  to  obliterate  pain, 
and  the  child  can  be  very  comfortably  carried  on  it.  In 
spinal  cases  he  may  lie  and  kick  all  he  pleases  if  his  feet 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  253 

are  warmly  clad.  As  to  bodily  clothing,  otherwise,  when 
he  is  applied  to  the  frame,  he  wears  only  undershirt  and 
diaper.  His  warm  dress  is  put  on,  last  of  all,  over  the 
jacket  of  the  frame.  Two  thick  pads  of  felt  are  sewed 
on  the  canvas,  each  7  inches  long  and  f  inch  thick,  to 
protect  the  hump  from  pressure  and  to  increase  the 
leverage  of  the  apparatus.  Mangle  felt  is  excellent  for 
orthopedic  purposes.  There  should  be  a  small  square  of 
rubber  covered  with  muslin  at  the  region  of  the  buttocks. 
To  make  the  frame  more  effectual,  it  may  be  bandaged 
with  strong  muslin  bandages,  with  edges  turned  in,  be- 
fore applying  the  laced  canvas  top.  This  frame  is 
gradually  bent,  under  the  kyphosis,  to  curve  upward 
from  the  bed  to  the  hump,  the  ends  resting  on  the  bed. 
This  obliterates  the  hump  in  time.  Much  orthopedic 
work  with  braces,  frames,  and  suspension  apparatus  is 
really  a  daily  "operation"  by  the  nurse.  The  child  is 
taken  off  the  frame  daily,  handled  painlessly,  bathed, 
rubbed  with  alcohol,  and  powdered.  It  is  essential  to 
have  two  canvas  covers  for  each  frame.  To  secure  the 
patient  to  the  frame  an  apron  of  canvas,  covering  the 
child's  chest  from  the  armpits  to  the  hips,  is  provided, 
with  three  pairs  of  straps  of  webbing  and  buckles,  fasten- 
ing in  the  back  on  the  under  side,  immobilizing  his  body. 
The  fixation  must  occur  in  the  region  of  the  disease — i.  e., 
for  lumbar  disease  a  broad  binder  should  be  passed  over 
the  hips,  and  if  there  is  psoas  spasm,  traction  is  usually 
employed. 

Buck's  extension  (Fig.  46)  consists  of  the  following  parts, 
all  of  which  should  be  kept  together  in  a  set  in  a  chest : 

(1)  Two  strips  of  moleskin  plaster,  each  2  or  3  inches 
wide  and  extending  from  the  seat  of  the  fracture  to  the 
internal  malleolus. 

(2)  An  alcohol  flame  to  melt  the  adhesive. 

(3)  Two  pieces  of  webbing  for  each  leg,  to  be  stitched 
to  the  plasters  at  their  ankle  end,  2  or  3  inches  wide  and 
6  inches  long. 

(4)  Five  other  strips  of  moleskin,  each  1^  inches  wide, 


254  OPERATING   ROOM 

to  encircle  the  leg,  the  knee,  and  the  thigh,  also  to  extend 
spirally  from  the  malleoli  around  the  leg  and  thigh  to  the 
seat  of  fracture. 

(5)  Roller  bandage  of  3-inch  muslin,  with  the  edges 
turned  in  during  application,  then  stitched  in  neat  rows, 
to  be  kept  in  place. 

(6)  A  curved  or  straight  ham,  or  posterior,  splint  prop- 
erly padded. 


Fig.  46, — Apparatus  for  Buck's  extension,  with  rope  and  weights. 

(7)  Three  coaptation  splints  to  surround  the  thigh. 

(8)  Six  webbing  straps  with  buckles  or  strips  of  band- 
age to  be  used  as  straps. 

(9)  Fresh  sheets,  pillowslips,  or  towels  as  pads. 

(10)  A  straight  abdominal  binder  for  the  pelvis. 

(11)  A  long  axillary  or  outside  splint  of  wood,  4  inches 
wide,  from  the  axilla  extending  6  inches  below  the  sole 
of  the  foot. 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  255 

(12)  To  this  is  nailed  a  cross-piece   18  inches  long, 
making  a  T. 

(13)  Two  towels,  soft  and  old,  or  2J  yards  of  flannelette 
(one-fourth  the  width)  for  a  perineal  strap. 

(14)  Safety-pins  arranged  with  their  points  in  a  cake  of 
Castile  soap. 

(15)  A  pulley,  .screwed  into  a  broom-handle  cut  the 
right  height  or  attached  to  a  special  iron  bar  (part  of  the 
set)  that  clamps  in  two  places  to  the  bed  frame. 

(16)  A  spreader,  being  a  piece  of  wood  2  inches  wide 
and  a  little  longer  than  the  width  of  the  patient's  foot, 
with  a  hole  bored  in  the  center  for  the  cord,  on  which  hang 
the  weights  for  extension. 

(17)  A  piece  of  clothes-line  (cotton  rope)  4  or  5  feet 
long. 

(18)  Two  shock  blocks  to  elevate  the  foot  of  the  bed. 

(19)  Four   sand-bags    with    white   muslin    slips,    each 
20  inches  long  and  6  inches  wide. 

(20)  A  square  cradle,  made  of  pine,  fir,  or  cedar,  to  keep 
the  weight  off  the  limb. 

(21)  A  soft,  warm  old  blanket  for  the  limb,  lying  closely 
over  it. 

(22)  Cotton  covered  with  gauze  to  stuff  into  corners 
(this  prevents  fluff  from  spreading  through  the  bed). 

(23)  A  fracture-board  or  a  plain  level  old  door,  with 
holes  bored  through  it  to  air  the  mattress  on  the  under 
side. 

(24)  Needle,  thread,  thimble. 

(25)  Tape-measure. 

(26)  Weights,  graduated  and  recorded  as  to  amount, 
when  used. 

(27)  Anesthesia  set,  vaselin,  pus  basin,  towels,  etc. 

(28)  A  railroad   (old-fashioned,  but  still  in  vogue) — a 
track  of  wood  on  which  the  leg  glides  smoothly. 

Such  a  list  as  this,  combining  with  the  basic  articles 
here  enumerated  any  favorite  materials  of  the  operator, 
should  be  posted  in  the  treatment  room  where  this  sort 
of  work  is  done, 


256  OPERATING   ROOM 

The  Lorenz  operation  for  congenital  dislocation  of  the 
hip,  consisting  of  bloodless  reduction,  retention,  weight 
bearing. 

For  bloodless  reduction  no  instruments  are  required 
but  the  surgeon's  hands;  a  thick  folded  sheet  beneath  the 
patient's  buttocks;  a  wedge  of  wood  (for  all  but  tiny 
children)  about  5  inches  long,  3  inches  wide,  and  suitably 
padded  to  form  a  fulcrum  under  the  head  of  the  femur; 
a  second  sheet  folded  diagonally  to  make  traction  from 
the  perineum,  with  the  ends  tied  about  a  corner  of  the 
table. 

If  the  reduction  requires  two  sittings,  a  plaster  spica  is 
required  for  the  first,  and  certainly  after  the  last.  The 
following  special  articles  are  to  be  provided: 

(1)  A    close-fitting    long    stockinet    shirt,    one-half    of 
which  is  cut  and  sewed  to  cover  the  limb  as  a  drawer  leg 
would  do. 

(2)  This  drawer  is  " threaded"  with  a  long  bandage, 
called  the  scratcher,  which  runs  down  as  a  loop  inside  the 
drawer  and  up  outside  the  cast,  to  give  the  patient  or 
nurse  a  means  of  rubbing  the  skin  underneath  when  it 
itches. 

(3)  The  hip  or  pelvic  rest  to  elevate  the  body  for  all 
spica  work. 

(4)  Sheet-wadding,  with  glazed  surface  preferably,  or 
cotton  in  long  rolled  strips,  4   inches  wide,  to  cover  the 
pelvis  and  thigh  thickly. 

(5)  A  firm  bandage  of  muslin  for  elasticity  and  com- 
pression   (may    be    preceded    by    a    fine    smooth    gauze 
bandage) . 

(6)  The  plaster  spica,  very  thick  and  firm,  consisting 
of  a  dozen  or  more  ordinary  plaster  bandages,  embracing 
the  iliac  crests,  the  buttocks,  and  the  leg  to,  but  not  over, 
the  knee-joint. 

(7)  Plaster  scissors  to  cut  away  the  edges;  then  they 
are  everted. 

(8)  Stout  thread  with  needle  to  sew  the  stockinet  (when 
it  is  smoothly  turned  up  over  the  edges)  to  itself. 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  257 

(9)  The  stimulation  tray  with  the  anesthesia  set,  be- 
cause many  deaths  occur  from  the  violence  of  the  rupture 
of  these  congenital  adhesions  under  the  anesthetic. 

(10)  A  cork  sole  of  1|  to  3  inches  in  thickness  should 
be  early  ordered  for  the  affected  foot  when  walking  begins 
in  the  third  week. 

Ordinary  Plaster  Bandages. — In  hospitals  where  ortho- 
pedic surgery  does  not  constitute  a  special  branch  of  work 
there  are  at  least  many  occasions  when  plaster  casts  must 
be  applied.  To  make  the  bandages  are  required: 

(1)  A  large  flat  tray. 

(2)  The  best  of  crinoline,  of  a  standard  fineness  and 
thickness,  this  being  the  foundation  of  the  whole  system. 

(3)  Excellent  dental  plaster  of  Paris. 

(4)  A  spatula  to  apply  the  plaster  to  the  crinoline, 
though  most  nurses  prefer  to  go  ahead  with  the  bare 
hands. 

(5)  A  tape-measure  and  stout  scissors  to  measure,  cut, 
and  roll  the  crinoline  in  5-yard  lengths  of  the  usual  widths 
— 3,  4,  5,  and  6  inches. 

(6)  Small  round  tin  boxes,  one  for  each  bandage,  lidded, 
or  squares  of  blue  tissue   such  as  comes  with  cotton,  to 
roll  up  each  bandage  separately,  then  laying  them  on  their 
side  in  a  large  square  tin  box  with  lid,  to  be  kept  per- 
fectly dry. 

(7)  A  rubber  apron  and,  if   the    skin  is  abraded  or 
suffers  from  contact  with  irritating  clays,  thick  rubber 
gloves. 

(8)  A  solid  stool  and  table  with  foot-rest. 

The  bandage  must  have  all  the  plaster  it  can  hold,  and 
this  must  be  evenly  distributed  throughout  its  whole 
length.  It  is  set  on  the  left-hand  side,  unrolled,  filled 
with  plaster,  much  lying  under  it  on  the  tray,  smoothed, 
and  rolled  up  to  keep  it  ship-shape  on  the  right  as  one 
goes  along.  It  must  be  rolled  only  about  75  per  cent, 
tight — that  is,  fairly  loose — so  that  water  may  circulate 
between  the  layers  of  piaster  later.  It  is  of  vital  moment 
to  keep  up  the  stock  of  plaster  bandages.  If  on  any  one 

17 


258 


OPERATING   EOOM 


day  they  run  too  low,  they  should  be  replenished  that  same 

day  before  the  nurses  go  off  duty. 

For  putting  on  a  cast  the  following  articles  are  required : 
(1)  Gown,  rubber  apron,  and  unsterile  rubber  gloves 

for  the  surgeon  (also  rubbers  with  high  tops  to  cover  his 

shoes,  if  he  chooses). 


Fig.  47. — Curved  plaster-of-Paris  knife. 

(2)  Newspapers,  rubber  sheets,  etc.,  to  cover  the  floor. 

(3)  Ammonia,   alcohol,   or  vinegar  to   soften  the  old 
cast  or  cleanse  the  hands. 

(4)  Special  knife,  saw,  and  shears  for   cutting    casts 
(Figs.  47,  48,  49). 


Fig.  48. — Saw  for  plaster-of-Paris  cast. 

(5)  Stockinet,  shirt,  drawers,  or  stockings  of  cotton  or 
Balbriggan  to  protect  the  body  (the  pupils  should  save  all 
their  cast-off  white  hose  for  this  purpose,  especially  for 
arm  cases);  bandages  of  stockinet  are  good  for  any  por- 
tions of  the  body  not  ordinarily  clothed  with  knitted 
goods. 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  259 

(6)  Mangle  felt  in  strips  or  squares,  to  pad  or  give 
elasticity  with  compression. 

(7)  Sheet-wadding,    glazed,    preferable    to    cotton,    in 
many  rolled  strips,  4  inches  by  1  yard. 

(8)  Cotton,  alcohol,  and  powder  to  rub  and  pad  all 
humps  or  edges,  even  after  everting  the  stockinet  cuffs. 


Fig.  49.— Plaster-of-Paris  shears. 

(9)  Oiled  silk,  to  form,  at  the  edges  near  the  genitals 
a  surface  impervious  to  urine  or  stool. 

(10)  Hip  rest  of  metal  or  wood  (also  convenient  for  the 
spica  in  hernia)  if  no  orthopedic  table  is  to  be  had. 

(11)  A  large  enamel  basin,  8  inches  deep,  in  which  to 
set  the  bandages  on  end,  with  plenty  of  space  for  the 
water  to  submerge  them  plus  the  nurse's  hands,  without 
overflow. 


260  OPERATING   ROOM 

(12)  Water  at  the  temperature  of  100°  F.,  kept  so  by 
adding  hotter  from  time  to  time  from  a  pitcher  nearby; 
a  bath  thermometer. 

(13)  A  solid  table  protected  with  rubber  sheeting  and 
an  old  cotton  blanket. 

(14)  Old   soft   blankets   on  the   patient;   warm- water 
bottles,  each  with  two  covers  not  warmer  than  110°  F.; 
a  burn  through  a  cast,  not  being  easily  discovered,  is  apt 
to  be  very  deep  and  lasting. 

Special  Instructions  to  the  Nurse. — (1)  Set  the  ban- 
dages on  end,  only  one  at  a  time,  and  hold  them  so  with 
both  hands  until  they  are  wet  through.  Bubbles  begin 
to  rise  continuously  in  their  center,  and  when  these  bubbles 
cease  they  are  wet  enough. 

(2)  Squeeze    the    bandage    until    one-half    the    water 
oozes  out,  then  hand  it  to  the  surgeon  so  that  he  may 
take  the  bulk  of  the  roll  in  his  right  hand  and  the  free 
end  in  his  left.     The  distance  from  the  nurse's  basin  to 
the  surgeon's  hand  should  be  the  shortest  possible. 

(3)  Just  as  soon  as  the  nurse  relinquishes  one  bandage, 
she  removes  the  wrapper  and  steeps  a  second,  that  time 
corresponding  to  the  length  of  time  required  by  an  ex- 
pert orthopedic  surgeon  to  apply  one. 

(4)  When  all  are  on,  she   should,   with  both  hands, 
scoop  up  the  sediment  left  after  pouring  off  the  bulk  of 
the  water  and  pass  it  to  the  surgeon  or  keep  it  soft  and 
equally  mixed  while  he  makes  with  it  an  extra  coat  quite 
smooth  over  all. 

(5)  At  times  it  is  necessary  to  bolster  the  cast  by  first 
applying  a  plaster  splint  which  is  best  made  on  the  oper- 
ating-table.     Therefore  a  space  must  be  cleared  by  flex- 
ing the  patient's  other  knee,  or  on  the  work-table  used  by 
the  nurse,   a  glass   or  rubber  surface  being  preferable. 
The  measure  is  taken  on  the  limb,  then  a  wetted  bandage 
is  laid  flatly  on  the  table  and  folded  on  itself  longitu- 
dinally.    If  this  were  a  5-inch  bandage  it  would  make 
five  thicknesses  1  yard  long   and  5  inches  wide,  which 
would  probably  be  thick  enough.     These  splints  are  al- 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  261 


Fig.  50. — Fracture  and  orthopedic  table  in  position  for  treating 
fracture  of  .the  lower  extremity — adaptable  to  rontgenographic 
examination. 


Fig.  51. — Fracture  and  orthopedic  table,  illustrating  control  of  the 
leg  in  bone-plating  for  fractures. 


262  OPERATING    ROOM 

ways  made  the  single  width  of  the  bandage  provided. 
Their  length  depends  on  the  bone  being  set. 

(6)  When  a  cast  has  been  put  on,  the  old  cast  is  broken 
up  into  small  fragments  to  fit  the  trash-cans  easily,  and 
to  avoid  scaring  some  one  who  comes  across  a  ghostly 
"limb"  in  the  dark  basements. 

Most  important  of  all,  the  plaster  must  not  be  poured  into 
the  sink  or  hopper,  since  it  sets  and  stops  up  the  plumbing. 
The  basins  should  be  scooped  out  into  papers,  thickly 
wrapped  about,  and  put  into  the  trash-cans. 

Orthopedic  Tables. — It  is  most  unusual  to  find  a  stand- 
ard orthopedic  table  outside  the  special  hospital,  but  it  is 
an  excellent  though  very  expensive  article,  consisting  of  a 
series  of  contrivances  for  procuring  leverage,  elevation, 
gaps  to  pass  bandages,  extension,  etc.  (Figs.  50,  51). 

Adhesive  Plaster  Strapping  for  Flat-foot. — Adhesive 
plaster,  15  inches  long  and  3  inches  wide,  beginning  at 
the  outer  side  of  the  ankle,  just  below  the  external  malle- 
olus.  Adduction  of  the  foot  (drawing  it  up  inwardly  to 
form  an  artificial  arch) .  Passing  the  plaster  tightly  under 
the  sole,  up  the  inner  side  of  the  arch  and  leg.  Two  small 
strips  of  plaster,  1  inch  wide,  crossing  it  at  the  top,  to  keep 
it  in  place,  but  not  completely  encircling  the  leg  lest  they 
cut  off  the  circulation.  Measure  with  a  tape  before 
cutting.  Then  cut  a  series  of  six  strips  of  adhesive, 
15  inches  long  and  f  inch  wide,  and  cover  this  same 
area  again,  laying  the  back  edge  of  each  over  the  front 
edge  of  the  one  preceding,  and  catching  them  alternately 
in  a  -braided  or  basket  pattern,  coming  down  from  the 
top,  with  small  strips  running  horizontally,  working  down 
to  the  malleoli,  but  leaving  an  open  path  down  the  in- 
step, 1J  inches  wide,  which  may  be  bordered  with  two 
strips  of  the  proper  length  to  cover  the  raw  edges.  Over 
all  apply  a  firm  bandage.  This  should  be  removed  once 
a  week  with  ether  or  benzine,  the  foot  examined  and 
cleansed,  then  dressed  again. 

Other  orthopedic  work  than  what  has  been  mentioned 
would  not  be  undertaken  outside  a  special  hospital. 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  263 

Orthopedic  literature  can  be  had  in  great  quantities,  its 
appliances  are  numerous,  and  long  practical  experience  is 
absolutely  necessary  for  a  nurse  to  handle  the  little 
sufferers  without  inflicting  needless  pain.  Below  is  given 
a  list  of  terms  that  may  be  used  in  conversations  regarding 
orthopedic  cases  which  are  too  difficult  for  the  general 
hospital  to  handle,  but  about  which  a  nurse  has  a  reason- 
able curiosity.  Orthopedic  cases  are  very  long,  and  a 
nurse  undertaking  the  care  of  one  without  previous 
training  should  at  once  betake  herself  to  some  institu- 
tion to  get  the  "first  principles,"  since  her  patient  is  not 
an  "emergency."  Few  women  are  blessed  with  a  talent 
for  mechanics,  mathematics,  or  physics,  and  in  ortho- 
pedic nursing  all  the  skill  depends  on  a  knowledge  of- 
leverage,  weights,  pressure,  and  extension,  added  to  pa- 
tience, sympathy,  and  gentleness  of  touch.  Then, 
again,  the  special  hospital  has  a  staff  of  skilled  black- 
smiths, carpenters,  harness-makers,  and  shoemakers  who 
work  in  conjunction  to  make  a  fitted  support,  consisting 
of  a  shoe  and  a  brace  for  the  leg,  a  jacket  for.  the  body, 
or  a  piece  of  apparatus  with  collar  and  pulleys  for  self- 
suspension,  on  patterns  taken  by  the  surgeons. 

SOME   SPECIAL  APPARATUS 

Jury  Mast. — A  frame  of  tempered  steel,  leather  straps, 
and  canvas  to  straighten  and  lengthen  a  curved  spine, 
including  as  points  of  support  the  brow  and  chin  and  a 
point  in  the  plaster  jacket  well  below  the  deformity. 
Each  must  be  accurately  fitted  to  the  individual  and 
altered  to  suit  his  development.  The  hump  must  be 
well  padded.  Even  with  the  most  careful  intentions 
frightful  pressure-sores  are  caused  by  inexpert  handling. 

Fracture-box. — A  support  for  the  leg  when  the  tibia  or 
fibula  is  broken  (Fig.  52). 

Sayre's  Suspension  Apparatus. — A  tripod,  joined  flex- 
ibly at  the  top  and  securely  fastened  when  in  operation 
by  spikes  into  the  floor.  From  the  center  at  the  top  on  a 


264 


OPERATING   ROOM 


Fig.  52. — Fracture-box. 


Fig,  53. — Sayre's  suspension  apparatus  for  application  of  plaster 
jacket,  or  exercises. 


PREPARATIONS  BY  NURSE  IN  ORTHOPEDIC  SURGERY  265 

pulley  runs  a  halter,  adjustable  to  a  collar,  that  thus  sup- 
ports the  patient  by  the  neck  and -chin.  It  is  fitted  to 
him,  and  he  is  then  slowly  raised  until  his  toes  are  just  off 
the  floor.  Then  over  only  a  knitted  undershirt,  with  the 
proper  pads  and  "scratcher,"  a  plaster  jacket  is  applied 
(Fig.  53). 

Modified  Buck's  Extension  for  Hip  Disease. — There  is 
no  splint  as  for  fracture,  merely  the  weights.  The  patient 
is  secured  around  the  waist  by  a  folded  towel  from  which 
a  bandage  runs  up  to  the  head  of  the  bed.  With  large 
children  a  perineal  strap  may  be  used.  In  any  case,  the 
foot  of  the  bed  may  be  elevated. 

NOTES 

The  most  modern  bone  operation  is  that  of  transplanta- 
tion. For  Pott's  disease,  ununited  fracture,  etc.,  a  very 
small  piece  is  excised  from  the  tibia  and  dovetailed  into  a 
crevice  hewn  out  of  the  affected  area.  The  hole  in  the 
tibia  is  replaced  by  healthy  granulating  bone  tissue,  not 
callus.  Callus  occurs  in  fractures.  Small'  pins  of  tibia 
bone  are  inserted  in 'holes  drilled  in  the  graft  to  maintain 
it  in  situ,  just  as  a  clever  carpenter  secures  the  pieces  of  a 
chair  with  wooden  pegs. 


CHAPTER  XX 

IMPROVISED  OPERATING  ROOM  IN  A  HUMBLE 

HOME 

HINTS 

(1)  COLD  sterile  water,  boiled  in  CLEAN  kettles  the  night 
before  fora  morning  operation.     Have  enough  kettles. 

(2)  Hot  sterile  water,  boiled  similarly  a  short  time  be- 
fore the  surgeon's  arrival. 

(3)  Clean  towels,  old  pieces  of  muslin  of  the  size  of  a 
towel,  put  up  in  packages  the  day  before,  and  sterilized 
as  follows :  Tie  a  cloth  from  handle  to  handle  of  a  clothes- 
boiler  to  make  a  flat  hammock  above  2  gallons  of  water, 
and  on  that  lay  the  packages.     Lay  the  lid  in  position, 
and  to  its  handle  tie  a  heavy  smoothing-iron  to  hold  it 
down   ("steam  under  pressure"   or  confined).     Turn  on 
the  gas  and  boil  for  one  hour.     Remove  the  iron  gently, 
then  the  lid  very  gently,  so  as  not  to  permit  the  drops  to 
fall  on  the  packages.     Lay  them  in  a  clean  dry  place  to 
become  perfectly  dry,  or  dry  them  in  the  oven. 

(4)  Laparotomy  sheet,  table  covers,  etc.,  may  be  made 
out  of  sheets,  pillowslips,  etc.     Do  not  destroy  a  good 
sheet  for  a  laparotomy.     Rather   pin  in   position  four 
pillowslips,  fold,  and  sterilize. 

(5)  The  surgeon  brings  his  own  supplies — cap,  gown, 
mask,  gloves,  instruments,  catgut,  etc. 

(6)  Nowadays  there    is   no  reason  why  he  could  not 
bring  his  own  dressings,  but  if  he  could  not  the  nurse 
would  make  and  sterilize  a  sufficient  amount  the  day 
before. 

(7)  Saline  made  within  the  same  day  it  is  used  requires 
only  one  sterilization.     Two  1-quart  bottles  are  sufficient. 
The  saline  is  made  and  boiled,  if  possible,  the  day  before, 


IMPROVISED    OPERATING    ROOM    IN    A    HUMBLE    HOME     267 

filtered,  and  poured  into  two  boiled  bottles,  which  are 
then  plugged  with  gauze  and  cotton  and  sterilized  with 
the  dressings.  By  being  made  triple  strength  and 
diluted  twice  with  cold  water,  they  can  be  cooled  for  use 
if  sterilized  again  the  day  of  the  operation  (set  in  a  con- 
tainer of  water  and  brought  to  a  boil,  then  kept  at  boil- 
ing-point one  hour). 

(8)  Vaselin,  as  a  sterile  lubricant,  is  set  in  its  con- 
tainer   (lid   separate)    in   cold   water,   not   quite  to   the 
edge,  then  brought  to  a  boil  and  kept  boiling  for-  one 
hour.     After    cooling    in    the    container    (burned    fingers 
being  res  non  gratce  at  this  time)  it  is  aseptically  lidded 
and  set  aside.     A  small  amount  is  taken  out  on  a  sterile 
grooved  director  when  needed. 

(9)  Basins  for  the  hands,  during  the  case  will  be  found, 
from  the  gray  enamel  to  the  white  stone  china,  in  an 
old-fashioned   bedroom..    If  enamel  or  china,   they  are 
disinfected  by  standing  in  bichlorid  of  mercury  solution 
1  :  1000  (preceded  by  vigorous  scrubbing  and  rinsing). 

(10)  For  an  irrigator  (seldom  used)  a  boiled  douche- 
bag  or  can,  covered  with  a  towel  and  hung  on  a  weighted 
hat-tree  with  smoothing-iron  or  brick  tied  to  the  feet  so 
that  it  will  not  topple,  may  be  used. 

(11)  For  a  sponge  and  instrument  table  an  ironing-board 
passed  through  the  first  and  third  panels  of  a  clothes- 
horse,  and  all  covered  with  sterile  sheets,  makes  a  safe 
place,  easily  set  up  and  put  away. 

(12)  For  operating-table,  an  extension  table  is  good, 
fully  extended  and  the  middle  leaves  taken  out  and  laid 
longitudinally,    well   padded   for   the   patient's   comfort. 
The  width  at  both  ends  makes  little  tables  for  the  operator 
and  anesthetist.     The  surgeon  and  his  assistant  stand  in 
the  " waist."     Or  two  small  tables,  tightly  and  solidly 
fastened  together,  padded  with  blankets,  sheets,  etc. 

(13)  For    improvised    Trendelenburg,    which    is    not 
likely  to  be  attempted  in  house  operations,  one  can  slip  a 
chair,  face  down  and  well-padded,  on  the  foot  of  the 
table,   or  an   assistant   standing   between   the   patient's 


268 


OPERATING   ROOM 


thighs  raises  her  legs  over  his  shoulders,  standing  with  his 
back  to  her,  or  one  may  elevate  the  foot  of  the  table 
with  blocks,  boxes,  or  solid  chairs,  propping  the  other 
end  to  keep  it  from  sliding. 

(14)  The  anesthesia  set  requires  a  pus  basin,  made 
from  a  large  soap  dish  or  a  soup  plate,  and  a  cone  for 
ether  for  the  closed  method  (Fig.  54)  made  out  of  a  towel 
and  a  folded  newspaper;  or  for  the  open  method  or  drop 


Fig.  54. — Closed  method  of  anesthesia. 

method  (Fig.  55)  of  either  ether  or  chloroform  a  piece  of 
flannelette  over  a  tea  or  coffee  strainer.  Most  anes- 
thetists would  bring  their  gas-ether  or  gas-oxygen  outfit 
with  them.  The  nurse  may  use  her  own  hypodermic 
syringe  for  stimulation. 

(15)  The  operation  is  rendered  too  dangerous  if  per- 
formed by  gaslight  or  lamplight  under  ether,  which  is  in- 
flammable and  volatilizes  in  a  long,  continuous  invisible 
train  that  connects  by-and-by  with  the  flame. 


IMPROVISED    OPERATING    ROOM    IN    A    HUMBLE    HOME     269 

(16)  Daylight  may  be  rendered  equally  diffuse  by  smear- 
ing Bon  Ami  on  the  lower  half  of  the  windows  and  at  the 
same  time  obscuring  them  to  the  gaze  of  the  passers-by. 

(17)  Oilcloth  and  thick  pads  of  old  newspapers  confined 
in  thin  old  sheets  or  gauze  will  protect  the  furniture, 
table,  blankets,  etc.,  from  blood,  water,  and  iodin. 

(18)  A  stretcher  is  made  by  laying  two  square  chairs 
face  down  on  the  floor,  their  feet  meeting.     The  legs  are 


Fig.  55. — Open  method  of  anesthesia. 

very  solidly  spliced  and  a  piece  of  board  laid  and  fastened 
in  the  center,  then  the  whole  covered  with  blankets  and 
draw-sheet.  The  upper  ends  of  the  chair  or  the  top  cross- 
piece  make  a  secure  handle/  This  stretcher  stands  at  a 
good  height  by  the  bed  for  lifting  the  patient  on  or  off 
with  the  aid  of  a  folded  sheet  (Fig.  56). 

(19)  If  vaginal  work  is  to  be  done  a  Kelly  pad  (Fig. 
57)  is  improvised  as  follows :  Required,  a  blanket,  old  and 
soft;  adhesive  strips,  6  by  2  inches;  a  rubber  sheet  or  a  piece 


270 


OPERATING   ROOM 


of  oilcloth,  2  yards  by  1  yard;  two  hemostats;  eight  pieces 
of  gauze  bandage  each  12  inches  long.     Roll  the  blanket 


tightly  and  tie  it  in  one  long  cylindric  roll.     Lay  it  on  the 
farther  long   edge   of  the   rubber  and  roll  toward  the 


IMPROVISED    OPERATING    ROOM    IN    A    HUMBLE    HOME     271 

nurse,  .about  two  turns.  Divide  into  three  equal  parts, 
the  middle  part  at  least  being  2  feet  wide.  Grasping  the 
roll  firmly,  turn  at  the  first  third  at  a  right  angle.  Do  the 
same  with  the  last  third.  This  leaves  a  triangle  outside 
each  side  of  the  "Kelly  pad."  Reduce  these  triangles 


Fig.  57. — Improvised  Kelly  pad. 


by  folding  to  one-half  their  size,  bring  over  the  roll,  inte- 
riorly, and  fasten  with  adhesive,  artery  clamps,  or,  at  the 
worst,  safety-pins,  in  the  oilcloth  only,  not  through  an 
expensive  rubber.  Let  the  apron  hang  over  into  the 
waste  pail.  The  whole  resembles  a  soldier's  blanket  on 
the  march. 


272  OPERATING   ROOM 

(20)  For  a  bed  operation  always  use  an  ironing-board 
or  the  leaf  of  an  extension  table  on  the  bed-frame  under 
the  springs  at  the  patient's  hips. 

(21)  If  a  nurse  is  far  from  her  base  of  supplies,  and  has 
to  improvise  a  gown  in  a  hurry,  it  may  easily  be  done  as 
follows:    Take   one   large  sheet  and  fold  the  long  edge 
over  about  12  inches.     Mark  the  center  of  this  fold  to  go 
over  the  breast.     Make  plaits  facing  to  the  center  all 
along  this  fold,  reducing  the  gown  in  size  to  fit  the  shoulders 
with  large  safety-pins  or  bastings.     Pin  or  stitch  to  the 
back  of  the  neck  two  tapes  each  12  inches  long.      Fold 
the  whole  in  the  uniform  method,  put  up,  and  sterilize. 
On  opening  it,  it  is  placed  by  the  now  scrubbed  nurse, 
before  her,  so  that  the  tapes  are  in  position  to  be  tied  by 
any  unscrubbed  assistant,  who  then  takes  the  very  tip  of 
the  corner  of  the  sheet,  extended  along  her  arm,  and,  as 
she  pivots  about,  with  her  arm  out  as  a  lever,  winds  the 
fold  around  her  arm  so  that  it  envelops  it  completely  and 
is  pinned  to  her  back.     A  reverse  swing  puts  the  other 
corner  in  the  same  position. 

(22)  Improvised  masks  are  made  as  follows:  A  piece 
of  gauze  J  yard  square  is,  before  the  person  scrubs,  laid 
up  on  his  chin.     The  lower  two  points  are  twirled  and 
tied  up  on  top  of  his  head.     The  upper  two  corners  are 
twirled  and  tied  over  and  behind  the  ears. 

(23)  A  piece  of  gauze  1  yard  square  brought  (doubled 
diagonally)  from  the  back  of  the  neck,  barely  escaping  the 
tips  of  the  ears  and  tied  on  the  brow,  with  the  central 
point  tied  in  with  it,  makes  a  cool,  serviceable  cap. 

(24)  A  loose  pyjama  coat  with  a  skirt  made  of  a  draw- 
sheet  and  put  on  backward  makes  a  practical  gown. 

(25)  The  cleansing  operations  preceding  the  surgeon's 
arrival  take  place  the  day  before — taking  down  pictures 
and  hangings,  washing  the  walls  with  bichlorid  after  dust 
has  settled,  covering  the  carpet  with  thick  papers  or  ol'd 
sheets,  or  both,  screening  the  window  with  cheese-cloth 
for  ventilation,  and,  if  there  is  not  time  to  dismantle, 
hanging  sheets  over  everything  high  and  dusty.     One 


IMPROVISED    OPERATING    ROOM    IN    A    HUMBLE   HOME     273 

great  secret  of  modern  surgical  success  is  that  everyone 
hastens  so  fast  that  there  is  no  time  for  dust  to  fall  into 
a  wound  nowadays. 

With  modern  facilities  of  travel  and  the  increasing 
erection  of  hospitals,  these  conditions  would  likely  exist 
only  in  the  remote  wilds  or  in  a  case  of  virulent  contagion 
with  complications.  But  every  nurse  should  cultivate 
the  power  of  improvisation,  so  as  to  save  expense  of  every 
kind  and  in  every  place  where  the  illness  is  even  the 
slightest  financial  burden. 

18 


CHAPTER  XXI 

A  PLEA  TO  THE  SUPERINTENDENT  IN  BEHALF 
OF  THE   OPERATING  ROOM 

AXIOMS 

I.  CONSIDER  that  skill  is  worth  more  than  money,  and 
try  to  keep  a  capable  official  as  supervisor  of  the  operating 
room  by  giving  her  support  in  her  just  ambitions  for  her 
sphere  of  work. 

II.  Keep  the  Board   of  Governors  interested  in  the 
special  need  of  the  operating  room,  whether  it  be  of  an 
electric  cautery,  a  new  table  with  convenient  adjustments, 
or  larger  sterilizers. 

III.  Induce  the   auxiliary   societies   (in  small  institu- 
tions) to  come  and  learn  to  fold  gauze,  so  as  to  help  build 
up  large  reserves  of  operating-room  goods. 

IV.  Take  the  side  of  the  workers  in  your  own  official 
family,  and  by  learning  what  they  need,  and  thinking 
and  willing  constantly,  hypnotize  the  managers  to  buy  it. 

V.  Only  sell  sterile  goods  by  the  consent  of  the  super- 
visor,   who    knows    her    limitations— (a)    vacations;    (6) 
breakdown  of  apparatus;   (c)  sick  nurses,  etc.     Issue  a 
report  to  the  Medical  Board  monthly,  showing  all  the 
sales  of  such  goods. 

VI.  When  sterilizing  goods  for  outside  patients  who 
intend  to  be  operated  on  or  confined  at  home,  the  price 
should  be  in  proportion  to  the  value  which  the  supervisor 
bears  to  the  institution,  the  time  taken  in  the  process, 
and  the  cost  of  the  hospital  equipment,  all  of  which  is 
special  or  technical;  e.  g.,  $3.00  is  a  fair  price  for  steriliz- 
ing a  suitcase  of  goods  for  an  obstetric  case  when  the 
patient  can  afford  to  have  the  services  of  the  type  of 
physician    who    demands    those    dressings.     Where    pa- 

274 


A    PLEA    TO    THE    SUPERINTENDENT  275 

tients  are  very  poor  they  may  be  treated  on  the  hospital 
wards,  for  part  of  which  the  municipality  pays. 

VII.  Encourage  the  formation  of  an  operating-room 
library,   with  special  works  of  reference  on  gross  and 
minute  anatomy,  surgery,  materia  medica,  vaccine  and 
serum  therapy,   pathology,   bacteriology,   etc.,   including 
cinematograph,  charts,  skeleton,  mannikin,  and  other  ob- 
jects for  demonstrating  purposes.     In  surgery,  the  text- 
books should  vary  according  to  the  variety  of  work  under- 
taken— orthopedics,  eye,  ear,  nose  and  throat,  general, 
gynecologic,  etc.     Very  frequently  a  patient  going  home, 
pleased  with  his  treatment  and   particularly  interested 
in  the  spotless  operating  room,  asks  what  he  could  give, 
and,  instead  of  saying  "money,"  ask  for  some  books  to 
better  that  service. 

VIII.  When    things    are    required    for    the    operating 
room  for  some  specific  purpose  get  them  immediately. 
Send  an  orderly  as  a  special  messenger.     If  these  articles 
required  could  have  been  asked  for  previously,  and  were 
not,  by  some  one's  neglect,  visit  your  wrath  on  the  guilty 
one,  but  get  them  immediately  none  the  less,  so  that  the 
patient  will  not  suffer.     It  would  be  wholesome  to  have  the 
offender  pay  the  messenger's  carfare  or  the  long-distance 
telephone  expenses. 

IX.  Give  the  supervisor  and  pupils  time  off  to  visit 
other  hospitals  where  surgery  is  particularly  well  carried 
on,  and  make  arrangements  ahead  to  have  them  met  and 
taken  around  to  see  the  salient  points  for  their  education. 
This  is  to  be  counted  to  them  as  work  and  their  expenses 
should  be  paid,  but  a  detailed  report  of  what  they  saw 
demanded  of  them. 

X.  Consult  the  corrmiittee  on  surgical  work,  a  part 
of  the  Medical  Board,  as  .to  means  of  progress,  and  use 
all  your  energies  to  induce  them  to  simplify  technic  and 
cut  out  unnecessary  fads  and  fancies. 

XI.  Become    a    member    of    the    American    Hospital 
Association  and  attend  its  meetings.       Take  an  active 
part  in  the  operating-room  work  discussions  and  learn  from 


270  OPERATING   ROOM 

others,  also  giving  the  benefit  of  your  own  experiences. 
Push  the  work  of  standardizing  all  operating-room  technic. 

XII.  In  small  village  hospitals  make  a  direct  appeal  for 
special  articles  to  the  people  through  the  daily  papers  and 
the  posting  of  lists  in  the  hospital  office,  showing  what 
articles  are  needed  in  the  operating  room. 

XIII.  When  the  office  is  notified  that  such  and  such  a 
case  is  coming   in,  notify  the   operating-room  supervisor 
at  once,  so  that,  in  the  event  of  immediate  operation,  she 
has  all  her  forces  at  her  disposal;  the  most  needed  nurses 
will  not  have  just  "gone  off  for  their  time"  or  some  big- 
cleaning   task   be   just   begun.     Never  defer   giving   the 
operating  room  any  information.     The  Duke  of  Welling- 
ton said  of  the  humid  atmosphere  of  Scotland,  "On.  a  fair 
day,  carry  your  umbrella;  on  a  wet  day,  suit  yourself," 
but  often  when  we  carry  an  umbrella  on  a  damp  day  we 
do  not  need  it,  and  often  when  in  a  state  of  semireadiness 
the  dreaded  event  does  not  occur. 

XIV.  Being  a  very  small  staff,  the  concentration  of  any 
rush  of  surgical  work  is  more  than  doubly  felt  by  the 
operating  room,  through  not  only  the  number  of  cases, 
but    their    dressings    and    sterilizing.     To    the    superin- 
tendent,  who   is   also   directress   of   nurses,   it   must   be 
urgently  remarked  that  by  adding  to  the  operating-room 
staff  in  a  rush  at  the  expense  of  other  wards  much  is 
really  gained.     It  does  not  pay  to  confront  any  human 
being  with  an  impossible  task,  and  where  a  very  robust 
young  woman  may  stand  ward  work  excellently,  she  may 
suffer  unheard-of  fatigue  in  the   operating   room  due  to 
(1)  tiled  floors,  (2)  steam-heated  and  steam-moistened  air, 
(3)  very  long  hours,  and  (4)  stairs,  in  some  hospitals,  to 
supply  rooms.     Good,  efficient  service  cannot  be  obtained 
from   fatigued    bodies   and   minds,    but   the   higher   the 
standard  of  our  care  of  nurses,  the  more  exacting  should 
be  our  discipline. 

XV.  Encourage  the  formation  of  an  extensive  reserve 
of  goods.     In  a  rather  slack  time,  between  seasons,  or  in 
a   period   of   very   good   municipal   health,   every   spare 


A    PLEA    TO    THE    SUPERINTENDENT  277 

moment  should  be  utilized  in  making  dressings,  dressing 
covers,  vaginal  sets,  etc.,  and  the  superintendent  who 
would  refuse  to  buy  gauze  or  unbleached  muslin  for  this 
purpose  does  not  know  her  business.  The  poor  patients 
are  maintained  by  charity,  and  both  those  who  can  give 
charitable  funds,  and  those  who  pay  their  own  expenses 
have  made  their  money  by  forethought  and  providence, 
and  certainly,  if  they  only  knew,  would  make  mock 
of  any  institution  working  on.  a  narrow  margin.  These 
institutions  are  not  commercial,  not  to  be  regarded  as  in 
any  possible  way  self-supporting.  It -is  the  duty  of  the 
municipality  to  provide  for  its  sick  in  the  most  efficient 
way  by  obtaining  skilled  officials  and  excellent  materials. 
The  cost  of  100  yards  or  more  of  gauze  or  muslin  do  not 
come  out  of  any  special  person's  pocket,  and  yet,  while 
giving  that  $2  or  $15  is  a  relief  to  the  man  who  thus  per- 
forms his  charitable  duty,  it  is  vastly  more  so  to  the 
strained  mind  of  the  anxious  nurse  who  wants  to  feel 
that  she  is  safe,  no  matter  what  emergency  arises.  True 
economy  in  a  hospital  is  based  on  (1)  getting  a  good 
quality  of  goods,  (2)  following  them  up  to  prevent  steal- 
ing, burning,  destruction. 

XVI.  The   laundry   is   responsible   to   the   matron   or 
housekeeper,  who  should  be  directly  responsible  to  the 
superintendent  of  nurses.    In  a  private  home  the  laun- 
dress is  not  responsible  to  the  man  of  the  house.     But 
either   directly   or   indirectly   though   this   may   be,   the 
laundry  must  pay  special  attention  to  all  operating-room 
linens,  and  there  should  be  a  waiving  of  red  tape  to  help 
the  supervisor  of  the  operating  room  get  a  special  set  of 
articles  rushed  through  at  any  one  time,  or  to  have  her 
stock  collected  and  laundered  oftener  than  the  wards 
do.     This   requires   rules  and   checking   up.     Operating- 
room  stuff  must  be  cleared  out  at  all  times  in  the  laundry. 

XVII.  Many  times  the  superintendent  is  persona  now 
grata  in  the  operating  room  because  he  seems  frigid  and 
unsympathetic  with  the  nursing  staff,  or  too  much  in- 
clined to  take  charge  of  them  and  tell  them  what  to  do. 


278  OPERATING    ROOM 

Again,  sometimes  a  woman  of  loud  voice  or  arrogant 
manner  may  seem  to  take  charge  of  the  whole  operating 
room,  surgeons  included,  creating  a  decidedly  unpleasant 
atmosphere.  It  is  occasionally  possible  that  one  whose 
duties  are  far  from  asepsis  and  vigilance  in  detail,  un- 
mindful of  the  little  niceties  of  position  in  the  operating 
room,  inadvertently  bumps  up  against  sterile  tables  in  a 
way  that  would  bring  down  a  sharp  reminder  if  it  were 
done  by  only  a  pupil.  All  persons  entering  an  operating 
room  are  subject  to  the  will  of  the  surgeon,  and  are  in  the 
presence  of  life  and  death.  No  visit  should  be  made, 
then,  unless  its  purport  bears  directly  on  the  immediate 
event,  and  no  conversation  should  take  place  except  for 
the  benefit  of  the  case  during  that  vital  period.  If,  per- 
adventure,  a  visitor  detects  a  nurse  making  an  error,  it 
should  be  corrected  through  the  supervisor. 

XVIII.  Politics,  relating  to  the  influence  of  one  surgeon 
more  than  another,  must  not  enter  into  a  superintendent's 
policy.     This  is  mentioned  here  since  the  surgeons  usually 
bring  the  best  paying  cases  to  the  hospital,  and  the  oper- 
ating room  fees  are  a  source  of  revenue.     A  capable  super- 
intendent is  one  who  lives  by  the  Ten  Commandments 
and  the  Golden  Rule.     The  official  who  can  be  strictly 
impartial  to  all  men,  and  yet  provide  them  good  satis- 
factory service  is  very  valuable  to  the  institution. 

XIX.  It  is  very  obvious  to  doctors  and  nurses  if  a 
superintendent   visits   the   operating   room   only   to   see 
certain  favorite  surgeons  operate,  or  to  see  certain  fashion- 
able patients  operated  on.     It  causes  discussion,  mockery, 
and  disrespect,  and  is  based  on  partiality,  an  insidious  foe 
to  good  administration. 

XX.  The  appointment  of  orderlies  for  this  service  is  in 
some  hospitals  the  duty  of  the  superintendent,  and  should 
be  a  matter  of  extreme  care,  since  they  should  be  men  of 
intelligence  and  good  habits.     They  live  on  rather  close 
footing  with  the  nurses  for  ten  hours  a  day,  and  they  also 
must   assist   the   surgeons   in   genito-urinary   operations. 
While  engaged  and  paid  by  one  official,  they  work  for 


A    PLEA    TO   THE    SUPERINTENDENT  279 

another,  and  might  run  to  both  with  complaints.  On 
being  engaged  they  should  be  impressed  by  the  super- 
intendent that  they  are  entirely  at  the  command  of  the 
operating-room  supervisor  as  to  duties,  relief,  hours,  etc. 
There  will  be  no  trouble  when  they  see  perfect  coopera- 
tion between  the  office  and  the  operating  room. 

XXI.  The  superintendent  should  visit  the  operating 
room  at  regular  intervals,  as  the  rest  of  the  house,  to  see 
what  repairs  or  improvements  can  be  made,  but  at  an 
hour  suitable  to  the  supervisor.  •  He  should  also  have  a 
schedule  for  visiting  the  cases,  but  so  arranged  as  to  treat 
all  in  fairness.  By  showing  a  technical  knowledge  on 
some  salient  point  and  no  ignorance  of  common  things 
he  fortifies  his  own  position  in  the  house. 


CHAPTER  XXII 

THE    CHOICE    AND    APPOINTMENT    OF    AN 
OPERATING-ROOM   SUPERVISOR 

To  have  a  superior  type  of  woman  in  this  position 
tells  so  strongly  in  the  complete  training  of  pupils  that 
the  boards  cannot  take  too  much  care  in  their  selection. 
Again,  the  services  rendered  the  surgeons  must  be  per- 
formed in  such  an  impartial  and  efficient  way  to  keep  up 
the  reputation  of  the  institution  that  her  character  must 
be  equalled  by  her  a'bility.  Possibly  more  than  any 
other  official  she  comes  nearer  to  the  superintendent  of 
the  institution,  excepting  always  the  chief  executive  of 
the  nursing  department,  since  her  buying  is  technical,  her 
department  so  fertile  in  revenue,  and  nursing  in  its  com- 
moner sense  all  but  eliminated.  Nevertheless,  she  is 
first,  last,  and  always  a  nurse.  Her  diploma  reads  identi- 
cally the  same  as  any  other  nurse's.  To  avoid  any  possi- 
bility of  disloyalty  or  friction  she  should  work  under  the 
jurisdiction  of  the  superintendent  of  nurses,  to  whose  class 
or  type  she  wholly  belongs. 

The  most  important  features  in  the  make  up  of  a  fine 
supervisor  are  summed  up 'as  follows: 

(1)  A  good  sound  physique,   and  a  rather  practical, 
calm  mind. 

(2)  Presence  of  mind,  determination,  system  in  work- 
ing. 

(3)  Dignity  toward  the  pupils  and  a  little  aloofness 
from  them  always. 

(4)  Good  principles  always  lived  up  to,  generosity  of 
disposition,  and  a  searching  grasp  of  human  nature. 

(5)  Sympathy    with   the    sick,    especially   with    those 
overtaken  by  sudden  accident  or  pain,  and  willing  service 
in  emergencies. 

280 


THE    CHOICE    AND    APPOINTMENT    OF    A    SUPERVISOR      281 

(6)  Excellent    education,    much    reading,    and    good 
manners. 

(7)  Breadth  of  experience  and  wide  observation,  both 
of  things  professional  and  things  mundane. 

If  any  woman  in  the  world  but  a  nurse  were  asked  to 
measure  up  to  all  that  she  would  quail.  But  many 
points  have  been  omitted,  and  yet  if  a  nurse  fails  to  gain 
approval  on  any  one  of  these  things  we  magnify  her 
failure  instead  of  trying  to  help  her  to  remedy  it. 

However,  in  applying  for  a  new  position,  the  future 
supervisor  presents  the  diploma  of  her  training-school, 
her  State  license  to  wear  "R.  N."  tacked  on  to  her  name, 
and,  let  it  be  here  suggested,  a  genuine  and  sincere  state- 
ment from  her  Alumnae  Association,  drawn  up  by  a  com- 
mittee from  her  own  class,  who  know  her  better  than  any- 
one else.  Think  what  an  effect  that  would  have  on  the 
present-day  nurses!  No .  hospital  official  should  ever 
consider  engaging  supervisors  who  do  not  wear  the 
R.  N.  It  is  the  duty  of  each  institution  getting  public 
moneys  to  assume  its  share  of  the  responsibilities,  created 
by  its  very  existence,  for  the  State  Board,  or  Regents, 
who  have  systematized  and  caused  to  be  accepted  by  the 
legislature  an  emblem  of  ability  and  character  for  all 
worthy  applicants  who  have  in  their  turn  also  carried  out 
their  own  responsibilities  to  their  school  and  to  them- 
selves. Therefore,  if  equally  stringent  means  were  taken 
to  encourage  nurses  daily  to  earn  their  future  commenda- 
tion, it  would  remodel  the  whole  internal  working  of  the 
present  training-school  system.  Furthermore,  when  a 
nurse  voluntarily  adopts  a  "specialty"  like  operating-room 
work,  it  is  to  be  hoped,  and  not  assumed  but  carefully 
determined,  that  (1)  she  is  suited  for  it;  (2)  she  will  con- 
tribute to  it  some  additions  in  invention  or  discovery; 

(3)  she  will  not  have  first  failed  in  other  fields  of  nursing: 

(4)  she  will  be  a  good  model  for  pupils  to  study. 

But  an  applicant  cannot  demonstrate  this  at  one  or 
many  interviews.  It  must  be  down  in  black  and  white. 
It  is,  therefore,  here  suggested  that  the  State  Boards 


282  OPERATING   ROOM 

form  a  standard  to  which  all  who  style  themselves  oper- 
ating-room supervisors  must  measure  up,  consisting  of  a 
test  taken  every  three  years,  and  embracing  these  features : 

(1)  Previous  records  of  skill,  executive  ability,  character; 

(2)  oral  examination  in  newer  materia  medica,  technic, 
etc.;  (3)  practical  demonstrations  in  demonstrating  to  a 
pupil  (a)  aseptic  technic;  (6)  making  dressings;  (c)  making 
solutions,  etc. 

The  examiners  should  be  surgeons  and  nurses  in  the 
van  of  surgery  and  nurses'  practical  affairs,  also  including 
instructors  in  pedagogics  for  nurses.  There  is  just  as 
much  pedagogy  required  in  teaching  a  nurse  as  in  teaching 
literature  or  geometry. 

The  applicant  for  any  position  should  make  a  written 
request  for  an  interview  with  the  superintendent  of  nurses, 
enclosing  copies,  not  the  originals,  of  her  degrees  and 
letters  of  commendation.  Meanwhile  she  will  have 
made  inquiries  from  every  source  at  her  command, 
personal  and  professional,  about  the  town,  the  people, 
the  industries,  the  means  of  transit,  as  well  as  the  hospital 
with  its  house  officials  and  staff  of  surgeons.  For  this 
purpose  medical  directories  and  State  reports  of  hospitals 
and  training-schools  classified  on  cold,  hard  facts  are 
available  to  every  one. 

When  the  superintendent  of  nurses  has  had  a  searching 
and  satisfactory  interview  with  the  nurse  supervisor,  who 
presents  now  her  true,  original  letters,  she  visits  with  her, 
by  previous  appointment,  the  office  of  the  superintendent, 
who  is  entitled  to  be  thoroughly  posted  as  to  the  qualifica- 
tions of  such  an  important  applicant.  From  his  stand- 
point again  a  searching  talk  bearing  on  the  business  rela- 
tions of  the  operating  room  to  the  institution  should  be 
held,  probably  placing  before  the  nurse  a  few  examples 
of  "political"  difficulties  that  arose  in  the  past  and  asking 
her  how  she  would  meet  them.  It  is  not,  however,  for 
the  superintendent  to  instruct,  appoint,  or  command  this 
nurse.  That  would  be  expressed  by  him  to  her  only 
through  the  conferences  he  would  later  hold  with  the 


THE    CHOICE    AND    APPOINTMENT    OF   A    SUPERVISOR      283 

superintendent  of  nurses.  Of  course,  in  a  busy  staff  it 
would  be  impossible  for  the  latter  to  be  always  present, 
but  when  addressing  the  supervisors  anywhere  the 
superintendent  should,  by  courtesy,  always  imagine  her  to 
be  there,  and  never  say  anything  that  he  would  not  say 
if  she  were  there.  As  men  usually  deal  with  men,  he 
would  not  give  orders  to  a  fireman  "over  the  head"  of  the 
engineer.  The  comparison  may  seem  crude,  but  the 
principle  of  responsibility  is  the  same.  He  is  not  a  nurse, 
and  there  are  no  diplomas  yet  issued  for  superintendents — 
speed  the  day! — with  all  due  respect  to  the  many  excellent 
superintendents  who  have  graced  their  gubernatorial 
chair  in  metropolitan  institutions  with  a  patience,  execu- 
tive skill,  and  tact  almost  unbelievable. 

Assuming  that  the  two  chief  officials  agree  about  this 
applicant,  an  appointment  should  be  made  that  she  could 
meet  the  committee  on  surgical  business,  a  flexible  and 
fairly  chosen  live  body  of  men  in  the  Medical  Board. 
These  men  should  question  the  nurse  until  they  are 
themselves  satisfied  that  she  has  a  good  .record  and 
knows  her  business ;  even  if  they  have  to  take  her  to  the 
operating  room  and  make  her  demonstrate  difficult  work 
there. 

When  all  these  persons  agree,  and  the  nurse  finds  the 
place  suitable  as  far  as  she  knows,  the  appointment  is 
ratified  by  the  Board  of  Governors  in  a  formal  letter, 
since  they  are  responsible  for  her  salary  and,  at  the  close 
of  an  engagement  that  was  very  efficient  on  her  part,  for 
her  record.  Boards  are  continuous  in  existence,  but  a 
superintendent  of  nurses,  in  small  hospitals,  frequently 
changes  her  position,  and  her  office  need  not  be  bound  by 
any  obligations  created  by  a  predecessor.  Obligations 
must  be  in  black  and  white  and  ratified  by  a  responsible 
person  or  body,  but  in  courtesy  to  one's  own  profession 
many  are  continued,  that  make  for  the  well-being  of  some 
workers. 

In  some  states,  like  Maryland,  certain  hospital  officials 
are  bonded,  and  then  given  great  responsibilities  with, 


284  OPERATING    ROOM 

naturally,  greater  freedom.  But  where  no  hostages  are 
given,  no  obligations  should  be  incurred. 

An  operating-room  supervisor  should  make  up  her 
mind  as  to  what  she  wants,  what  she  can  have,  and  how 
to  make  the  best  of  what  is  offered;  finding  this  within 
her  scope,  she  naturally  accepts.  She  should  get  accu- 
rate, reliable  information  about  the  length  of  her  vaca- 
tions, with  or  without  pay,  the  hours  for  work  .and  recrea- 
tion, her  other  duties,  if  any,  in  the  institution  outside 
her  own  sphere,  her  relief,  her  private  quarters,  and  all 
points  relating  to  the  management  of  the  operating  room ; 
for  example,  the  authority  of  the  Medical  Board  or  its 
committees,  the  number  of  surgeons,  the  nature  and 
average  amount  of  cases,  the  number  of  pupils  at  one 
time,  the  methods  of  caring  for  night  cases,  etc. 

Business  registries,  run  for  financial  reasons  alone,  are 
not  the  best  sources  of  information  for  either  the  hospitals 
or  the  nurses,  since  they  thrive  on  the  number  of  "deals" 
they  close,  and  do  not  comprehend  the  ethics  and  technic 
of  the  profession.  Yet  there  are  some  very  excellent 
registries  conducted  on  that  basis. 

School  registries  do  not  make  enough  effort  to  promote 
this  business  side  of  their  profession,  on  the  other  hand. 
While  emanating  from  the  finest  hospitals,  where  natur- 
ally one  would  expect  to  find  good  young  executives  "in 
the  bud,"  they  simply  busy  themselves  with  sending 
nurses  out  to  private  practice. 

A  model  registry  should  be  that  conducted  by  nurses 
for  nurses,  for  executive,  educational,  operating,  district, 
school,  and  private  positions.  But  these  fail  terribly  at 
times  through  being  entirely  too  ethical.  Few  people 
can  write  a  really  honest  testimonial.  The  nurses  who 
wish  to  do  institutional  work  present  insincere  docu- 
ments, which  pass  the  censor,  whether  through  indiffer- 
ence or  a  mistaken  desire  to  be  ethical.  It  is  time  to  ex- 
pose this  false  free  masonry  which  has  not  put  the  nurses 
through  any  real  test.  It  takes  a  very  great  deal  of  ex- 
pense and  time  to  verify  testimonials,  and  that  is  what  a 


THE    CHOICE    AND    APPOINTMENT    OF    A    SUPERVISOR      285 

registry  is  paid  to  do.  But  it  is  often  neglected,  with  the 
result  that  invalid,  irritable,  unskilled  failures  are  foisted 
on  busy,  strenuous  high-grade  hospitals,  to  the  disgust  of 
all  who  try  charitably,  in  spite  of  first  impressions,  to  give 
them  time  "to  make  good." 

Some  hospitals  make  it  an  unvarying  rule  never  to 
take  on  an  official  or  employee  who  is  at  the  time  "out  of 
a  job."  While  this  has  its  exceptions,  it  will  be  found, 
in  the  main,  to  work  well. 

There  should  be  a  period  set  in  all  business  arrange- 
ments, as  a  "notice"  for  the  termination  of  the  contract, 
to  avoid  irregularities  in  paying  salaries,  and  sudden 
upheavals  of  departure,  a  month  being  none  too  long  to 
give  a  hospital  a  sufficient  chance  to  find  a  good  super- 
visor, while,  if  the  nurse  were  at  fault,  it  might  take  her 
much  longer  to  find  a  position,  and  yet  she  could  imme- 
diately do  private  nursing,  which  compensates. 

One  thing  most  of  all  to  be  avoided  is  "one-man"  ap- 
pointments and  "one-official"  pulls.  It  is  not  a  healthy 
condition  of  affairs  where  a  nurse  obtains  -a  position 
through  the  influence  of  any  man  with  whom  she  will 
afterward  be  closely  identified  in  the  operating  room. 
It  creates  a  feeling  of  indebtedness  that  she  wishes  to 
pay  off.  She  then  becomes  unjust  to  other  surgeons,  and 
partiality  is  an  insidious  and  heinous  crime,  burrowing  its 
filthy  roots  through  the  whole  structure.  It  would  be 
no  harm  for  an  orthopedic  surgeon  to  recommend  some 
clever  nurse  he  knew  to  an  eye  and  ear  operating  room 
where  he  did  not  work.  Similarly  with  the  house  staff, 
if  the  officials  cannot  agree  that  one  applicant  is  worthy, 
better  sacrifice  her  than  the  serenity  that  should  exist 
between  the  heads,  unless  the  objector  can  be  proved 
wrong  by  overweight  of  evidence.  Neither  is  it  health}^ 
to  have  undue  interest  on  behalf  of  any  one  member  of 
the  Board  of  Governors  in  any  supervisor.  A  little 
creeping  up  of  her  salary  now  and  again,  or  longer 
vacations  with  pay  will  create  a  jealousy  among  the 
others  in  which  her  life  will  naturally  be  unhappy.  A 


286  OPERATING   ROOM 

nurse  should  always  be  approved  or  condemned  by  her 
peers. 

This  may  be  happily  solved  some  day  by  the  American 
Hospital  Association.  In  it  is  a  way  out  of  most  of  our 
difficulties.  If  the  position  of  operating-room  nurse  be 
standardized  in  all  its  features,  and  if  these  nurses  also 
meet  specially  in  committee,  to  learn  from  one  another, 
study  exhibits,  hear  lectures  from  the  greatest  surgeons, 
and  improve  their  minds,  the  hospitals  engaging  them  will 
be  sure  of  much  of  their  hoped-for  aim. 


THE  GOSPEL  OF  WORK 


A  MODERN  NURSE'S  QUINT ALOGUE 


I.  Want  something. 
II.  Know  what  you  want. 
HI.  Determine  to  get  it. 
IV.  Think  the  best  way  to  get  it. 

V.  Work  to  get    it,   and  as  fast    as    you're 
knocked  down,  get  up  again  and  go  on. 


-Anonymous. 


287 


INDEX 


ABSCESS  of  brain,  instruments  for 

operation,  192 
pharyngeal,  192 

Acumen,  business,  22,  71 

Adenoids,    removal    of,     instru- 
ments for,  191 

Adhesive,  how  to  sterilize,  150 

Advancement,  88 

Albee  electro-operative  bone  set, 
76 

Alcohol,  denatured,  232 
bonds  for,  232 

Aluminum  acetate  solution,  138 

Ambulance,  71,  72 
bags,  70 

American   Hospital   Association, 
275 

Amputation    of    breast,    instru- 
ments for,  193 

Anatomy,  29 

Anesthesia,  rectal,  63 
spinal,  63,  248 

Anesthetics,  local,  142 
special,  63 

Anesthetists,  55,  57,  65,  127 
nurse,  58 

Aneurysm  needles,  201 

Appendectomy,  instruments  for, 
196 

Applicators,  161 

Argyrol,  142 

Aristol  pledgets,  160 
19 


Artificial  respiration,  Sylvester's 

method,  249 
Asepsis,  114 

breaks  in,  128 
Attendants,  health  of,  130 
Autoclaves,  106 
Axioms,  274 

BANDAGING,  160 

Beck  nasal  packing  bags,  189 

Bed,  Gatch,  44,  49 

Bichlorid  of  mercury  solutions, 

140 
Binder,  breast,  193,  221 

Scultetus,  219,  220 

T-,  how  to  make,  162,  219 
Bistoury,  205 
Blanket  warmer,  110 
Blankets,  228 
Blood,  transfusion  of,  244 
Blood-letting,  246 
Blood-serum,  injection  of,  243 
Bone,  transplantation  of,  265 
Bone-wax,  138 
Bore  of  needles,  151 
Boric  acid  solution,  139 
Bottles,  care  of,  134 
Bougies,  146 
Bow-legs,  250 
Bradford  frame,  252 
Brain,  abscess  of,  instruments  for 

operation,  192 

289 


290 


INDEX 


Brandy,  232 

Breast,    amputation    of,    instru- 
ments for,  193 
binder,  193,  221 
funnel,  250 

Buck's  extension,  253 

modified,  for  hip  disease,  265 

Bureau  of  Standards  and   Sup- 
plies, 231 

Burns,  sterilized  linen  for,  229 

Business  acumen,  22,  71 

Button,  empyema,  198 
Murphy,  73 

Buying  for  the  operating  room, 
230 

CANULA,  158 

Canule  a  chemise,  158 

Caps,  116,  221 

Carrel-Dakin  antiseptic,  136 

Cataract  operation,  instruments 

for,  188 
Catgut,  133 

chromicized,  137 

iodized,  137 

preparation  of,  137 
Catheters,  146 

silk,  147 
Cesarean  section,  instruments  for, 

202 
Cholecystectomy,       instruments 

for,  198 
Cholecystotomy,         instruments 

for,  198 
Choledochotomy,        instruments 

for,  198 

Chute,  laundry,  27 
Clean  nurse,  123 
Cloth  retractors,  160 
Club-foot,  252 
Cocain,  142 
Cold  cream,  hospital,  152 


Colostomy  bag,  204 
Contagion,  131 
Covers  for  dressings,  116 
Cubic  centimeter,  154 
Curettage,  instruments  for,  205 
Cysts,  evacuation  of,  99 

DAMPNESS  of  dressings,  115 

Dark  room,  95 

Details  in  nursing,  80 

Deterioration,  63 

Diagnosis,    surgical,    terms   used 

in,  163 
Dietetian,  70 
Discipline,  78 
Dislocation    of    hip,    congenital, 

250 

Dissection,  70 
Distillation,  107 
Donor,  245 
Dorsal  position,  50 
Draughts,  forced,  92 
Dressing-rooms,  nurses',  102 
Dressings,  22 

covers  for,  116 

dampness  of,  115 
Drop-forged  instruments,  68 
Dusting,  23,  127 

EAR,    radical    operation    on,    in- 
struments for,  190 

Eight-hour  duty,  32 

Electrical  apparatus,  97 

Electricity  for  sterilizing,  110 

Electrodes,  186 

Elevators,  102 

"Emanations"  of  radium,  101 

Emergency  cases,  131 
orders,  233 

Empyema  button,  196 

operation  for,  instruments,  194 

Engineer,  46,  106 


INDEX 


291 


Enucleation  of  eye,  instruments 

for,  191 
Errors,  detecting,  106,  109,  110, 

118 

in  technic,  122 
Ethical  relation,  87 
Eye,  enucleation  of,  instruments 

for,  191 
pads,  160 

FAULTS,  common,  81 

Filiforms,  146 

Filters,  105 

Fire-drill,  102 

Fistula    in    ano,    operation    for, 
instruments,  207 

Fixation  forceps,  188 

Flasks,  Florentine,  139 

Flat-foot,  252 

adhesive  plaster  strapping  for, 
262 

Floors,  110,  129 

Florentine  flasks,  139 

Folding  gowns,  226 
linen,  225 

Forceps,  68 
fixation,  188 

Formaldehyd,  141 

Formalin,  141 

Fracture  table,  261 

Fracture-box,  263 

Freezing  of  specimens,  148 

Frontal  sinus  operation,   instru- 
ments for,  189 

Fumigation,  93 

Funnel  breast,  250 

GANT  pad,  208 

Gastrectomy,     instruments     for, 

200 
Gastro-enterostomy  forceps,  199 

instruments  for,  200 


Gastrostomy,     instruments     for, 

200 

Gatch  bed,  44,  49 
Gauze,  iodoform,  136,  137 

oxygen,  59 
Genito-urinary      work,      nurse's 

presence  at,  33,  46 
Genu  valgum,  250 

varum,  250 
Gigli  saw,  185 

Glass  syringes,  sterilization  of,  151 
Glasses,  116 
Gloves,  rubber,  144 
with  holes,  134 
Glove-tree,  144 
Gown  covers,  225 
Gowns,  folding  of,  226 
Grafting,  skin-,  instruments  for, 

193 
Greeley  units  for  hypodermic  use, 

54 
Gutta-percha  tissue,.  143 

HALLUX  valgus,  251 

varus,  251 

Halsted's  silver  foil,  149 
Hand  lotion,  hospital,  152 
Handling  goods  from  jar,  124 
Harrison  law,  142 
Head  operations,  instruments  for, 

185 

Health  of  attendants,  130 
Hemolysis,  244 
Hemorrhoidectomy,   instruments 

for,  206,  207 
Hernia  knife,  204 
Herniotomy,  instruments  for,  203 
Hints,  general,  71 
Hip,  congenital  dislocation,  250 

disease,  251 

modified    Buck's    extension 
for,  265 


292 


INDEX 


Home,      improvised      operating 

room  in,  266 
Hopper  room,  113 
Horsehair,  138 

Hospital    Bureau    of    Standards 
and  Supplies,  231 

cold  cream,  152 

hand  lotion,  152 
Hypodermic   use,   Greeley   units 

for,  54 " 

Hypodermoclysis,  242 
Hysterectomy,  instruments     for, 

200 

IMPARTIALITY,  30     • 
Infusion,  intravenous,  234 

thermometer,  238 
Instruments,  care  of,  149 

contaminated,  128 

for  various  operations,  185 
Intravenous  infusion,  234 
lodoform  gauze,  136,  137 

thermometer,  238 
Iridectome,  188 

JARS,  care  of,  134 

Jugular  operation  following  sinus 

thrombosis,    instruments    for, 

190 
Jury-mast,  263 

KANGAROO  tendon,  138 
Kelly  pad,  improvised,  271 
Kidney  position,  50 
Knee-chest  position,  51 
Knee-swell,  96 
Knives,  68 
Knock-knee,  250 
Kyphosis,  251 

LABARRAQUE'S  solution,  229 
Lane's  bone  plates,  75 


Laparotomy  gowns,  220 

sheets,  222 

stockings,  220 
Laundry  chute,  27 
Law,  Harrison,  142 
Leg  rolls,  159 
Legal  phases,  81 
Ligatures,  68 
Linen,  217 

folding  of,  225 

for  isolated  cases  or  dirty  dress- 
ings, 229 

Lithotomy  position,  51 
Lordosis,  251 
Lorenz  operation,  256 
Lumbar  puncture,  247 
Lycopodium  powder,  146 

MACHE  units  of  radium,  101 
Mangle  felt,  259 
Masks,  116,  222 
Mastoid  dressing,  157 

operations,     instruments     for, 
186 

tips,  157 

Mayo's  gall-stone  scoop,  199 
Medical  Board,  18,  95,  119,  283 
Messengers,  special,  233 
Metric  System,  153 
Michell  clips,  198 
Mortise-lock,  68 
Moving-pictures,  34 
Murphy  button,  73 

NASAL  septum,  submucous  resec- 
tion, instruments  for,  188 

Needles,  bore  of,  151 
slip-ons  of,  68 
testing,  73 
threading,  67 

Nephrectomy,    instruments    for, 
203 


INDEX 


203 


Nephrotomy,     instruments     for, 

203 

Nitrate  of  silver,  141 
Nomenclature,  209 
Novice,  20,  21 
Noyocain,  142 

ORDERLY,  23,  57,  127,  130 
Orientation,  188 
Orthopedic  surgery,  250 

tables,  262 
Osteoclast,  251 
Oxygen  gauge,  59 

PACKING  covers,  225 

making  of,  160 
Pad,  Gant,  208 

Kelly,  improvised,  271 
Pads,  eye,  160 

special  table,  99 
Pathologic  tissue,  164 
Perineorrhaphy,  instruments  for, 

206 

Petticoated  tube,  158 
Pharyngeal  abscess,  192 
Pheasants'  feathers,  192 
Phlebotomy,  241,  246 
Plaster  bandages,  257 

of  Paris,  257 
Platinum,  75,  156 
Pledgets,  160 
Plumbing,  96 ' 
Politzer  bag,  196 
Position,  dorsal,  50 

kidney,  50 

knee-chest,  51 

Sims',  51 

Trendelenburg,  41,  51 
Potain's  aspirator,  237 
Pott's  disease,  252 
"Preparedness,"  77 


Pulmotor,  64 
Puncture,  lumbar,  247 

RADIUM,  101 
Rectal  anesthesia,  63 

specula,  206 
Respiration,     artificial,     Syl 

ter's  method,  249 
Retractors,  cloth,  160 
Rotation  of  service,  17 
Routine,  82  . 
Rubber  gloves,  144 

tissue,  143 

tubing,  146 

utensils,  care  of,  150 


SAFETY  devices,  109 
Saline,  cloudy,  108 

making,  139 

selling,  88 
Saw,  Gigli,  185 
Sayre's     suspension     apparatus, 

263 

Scholarships,  32 
Scoliosis,  252 
"Scratcher,"  265 
Scultetus  binder,  219,  220 
Self-government,  33 
Serum,  64 

blood-,  injection  of,  243 
"Setting-up,"  38 
Shoes,  130 
Silk  catheters,  147 

surgeons',  138 
Silkworm-gut,  138 
Silver  leaf,  149 

nitrate,  141 
Sims'  position,  51 
Skin-grafting,     instruments    for, 

193 
"Slip-ons"  (of  needles),  68 


294 


INDEX 


Solution,  Labarraque's,  229 
Specimens,  freezing  of,  148 

importance  of,  44 
Specula,  rectal,  206 
Sphygmomanometer,  246 
Spinal  anesthesia,  63,  248 
Splay  foot,  250 
Sponges,  small,  159 
Square  measure,  153 
Stains,  how  to  remove,  228 
Steam-pressure,  106 
Sterilization,  complete,  tests  for, 
107 

of  adhesive,  150 

of  rubber  gloves,  144 

of  vaselin,  152 
Sterilizing  room,  104 
Stovain,  248 
Strabismus  hook,  191 

operation  for,  instruments  for, 

190 
Stretchers,  99 

improvised,  269 
"Submucous,"  188 
Suits,  purchase  of,  229 
Superintendent,  plea  to,  274 
Supervisor,  choice  and  appoint- 
ment, 280 
Supply-room,  162 
Surgeons'  silk,  138 
Surgical  diagnosis,  terms  used  in, 

163 

Sutures,  67,  75 
Sylvester    method     of    artificial 

respiration,  249 
Syringes,  64 

glass,  sterilization  of,  151 


TABLE  pads,  special,  99 

tonsil,  99 
Tact,  30 


Talipes,  252 

cquinus,  252 

planus,  252 

valgus,  252 

varus,  252 

Tampon  canula,  158 
Tampons,  159 
Tape  stickers,  161 
Tap-water,  135 
T-binder,     how    to    make,    1(52, 

219 

Teaching,  79 
Technic,  errors  in,  122 
Telephone,  22,  48 
Temperature,  92 
Tendon,  kangaroo,  138 
Terms  used  in  surgical  diagnosis, 

163 

Testing  needles,  73 
Thermometer,  infusion,  238 
Thiersch's  solution,  136 
Threading  needle,  67 
Thrombosis,  235 
Thrombus,  235 
"Tips,"  mastoid,  157 
Tonsil  table,  99 
Tonsils,  removal  of,  instruments 

for,  191 

Towels  with  holes,  134 
Trachelorrhaphy,        instruments 

for,  206 

Tracheotomy,     instruments    for, 
192 

tubes,  151 
Trade  names,  232 
Training  in  operating-room,   17, 

31 

Transfusion,  244 
Transplantation  of  bone,  265 
Trend elenburg  position,  41,  51 
Triple  strength  saline,  239 
Twigs,  47 


INDEX 


295 


VAGINAL  sheets,  223 
Vaselin,  sterilization  of,  152 
Venesection,  246 
Ventilation,  90 
Viscera  forceps,  197 
Volume,  metric  units  of,  154 
Vulsellum  forceps,  201 


WALLS,  129 
Waste  receptacles,  101 
Whisky,  232 
"Whistle,"  208 
Workrooms,  111 

ZEISS  light,  99 


Books  for  Nurses 


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Death,  Bandaging,  Care  of  Infants,  etc. 

Bacteriology  and  Surgical  Technic  for  Nurses.  By  EMILY  M.  A. 
STONEY.  Revised  by  FREDERIC  R.  GRIFFITH.  M.  D.,  New  York. 
12010  volume  of  311  pages,  fully  illustrated.  Cloth,  $1.50  net. 

Goodnow's  First-Year  Nursing    2d  EDITION 

Miss  Goodnow's  work  deals  entirely  with  the  practical  side  of 
first-year  nursing  work.  It  is  the  application  of  text-book 
knowledge.  It  tells  the  nurse  how  to  do  those  things  she  is  called 
upon  to  do  in  her  first  year  in  the  training  school — the  actual 
ward  work. 

First- Year  Nursing.  By  MINNIE  GoODNOW,  R.  N.,  formerly  Super- 
intendent of  the  Women's  Hospital,  Denver.  tamo  of  354  pages, 
illustrated.  Cloth,  $1.50  net. 


Aikens'  Hospital  Management 

This  is  just  the  work  for  hospital  superintendents,  training- 
school  principals,  physicians,  and  all  who  are  actively  inter- 
ested in  hospital  administration.  The  Medical  Record  says: 
"Tells  in  concise  form  exactly  what  a  hospital  should  do 
and  how  it  should  be  run,  from  the  scrubwoman  up  to  its 
financing." 

Hospital  Management.  Arranged  and  edited  by  CHARLOTTE  A. 
AIKENS,  formerly  Director  o?  Sibley  Memorial  Hospital,  Washing- 
ton, D.  C.  12010  of  488  pages,  illustrated.  Cloth,  $3.00  net 

Aikens'  Primary  Studies         NEW  <3d)  EDITION 

Trained  Nurse  and  Hospital  Review  says:  "It  is  safe  to  say 
that  any  pupil  who  has  mastered  even  the  major  portion  of 
this  work  would  be  one  of  the  best  prepared  first  year  pupils 
who  ever  stood  for  examination." 

Primary  Studies  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Director  of  Sibley  Memorial  Hospital.  Washington,  D.  C.  izmo  of 
47i  pages,  illustrated.  Cloth,  $1.75  net 

Aikens'  Training-School  Methods  and 
the  Head  Nurse 

This  work  not  only  tells  how  to  teach,  but  also  what  should 
be  taught  the  nurse  and  how  much.  The  Medical  Record  says: 
"  This  book  is  original,  breezy  and  healthy." 

Hospital  Training-School  Methods  and  the  Head  Nurse.  By  CHAR- 
LOTTE A.  AIKENS,  formerly  Director  of  Sibley  Memorial  Hospital, 
Washington,  D.  C.  lamo  of  267  pages.  Cloth,  $1.50  net 

Aikens'    Clinical    Studies       NEW (2d)  EDITION 

This  work  for  second  and  third  year  students  is  written  on  the 
same  lines  as  the  author's  successful  work  for  primary  stu- 
dents. Dietetic  and  Hygienic  Gazette  says  there  "is  a  large 
amount  of  practical  information  in  this  book." 

Clinical  Studies  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Director  of  Sibley  Memorial  Hospital,  Washington,  D.  C.  12010  of 
569  pages,  illustrated  Cloth,  $2.00  net 


Bolduan  and  Grund's  Bacteriology 

The  authors  have  laid  particular  emphasis  on  the  immediate 
application  of  bacteriology  to  the  art  of  nursing.  It  is  an 
applied  bacteriology  in  the  truest  sense.  A  study  of  all  the 
ordinary  modes  of  transmission  of  infection  are  included. 

Applied  Bacteriology  for  Nurses.  By  CHARLES  F.  BOLDUAN,  M.  D., 
Assistant  to  the  General  Medical  Officer,  and  MARIE  GRUND,  M.D., 
Bacteriologist,  Research  Laboratory,  Department  of  Health,  City  of 
New  York.  i2mo  of  166  pages,  illustrated.  Cloth,  $1.25  net. 


Fiske's  The  Body 


A  NEW  IDEA 


Trained  Nurse  and  Hospital  Review  says  "it  is  concise,  well- 
written  and  well  illustrated,  and  should  meet  with  favor  in 
schools  for  nurses  and  with  the  graduate  nurse." 

Structure  and  Functions  of  the  Body.  By  ANNETTE  FISKE,  A.  M., 
Graduate  of  the  Waltham  Training  School  for  Nurses,  Massa- 
chusetts. i2mo  of  221  pages,  illustrated.  Cloth,  $1.25  net 


Beck's  Reference  Handbook 


NEW  (3d)  EDITION 


This  book  contains  all  the  information  that  a  nurse  requires 
to  carry  out  any  directions  given  by  the  physician.  The 
Montreal  Medical  Jotirnal  says  it  is  * '  cleverly  systematized  am) 
shows  close  observation  of  the  sickroom  and  hospital  regime/' 

A  Reference  Handbook  for  Nurses.  By  AMANDA  K.  BECK.  GracS 
uate  of  the  Illinois  Training  School  for  Nurses,  Chicago,  Ilk 
32mo  volume  of  244  pages.  Bound  in  flexible  leather,  $1.25  net. 

Roberts'  Bacteriology  &  Pathology 

This  new  work  is  practical  in  the  strictest  sense.  Written 
specially  for  nurses,  it  confines  itself  to  information  that  the 
nurse  should  know.  All  unessential  matter  is  excluded.  The 
style  is  concise  and  to  the  point,  yet  clear  and  plain.  The  text 
is  illustrated  throughout. 

Bacteriology  and  Pathofogy  for  Nurses.    By  JAY  G.  ROBERTS,  Ph.  G., 

M.  D.,  Oskaloosa,  Iowa.     i2mo  of  206  pages,  illustrated.      $1.25  net. 


DeLee's  Obstetrics  for  Nurses 

Dr.  DeL,ee*s  book  really  considers  two  subjects — obstetrics 
for  nurses  and  actual  obstetric  nursing.  Trained  Nurse  and 
Hospital  Review  says  the  * '  book  abounds  with  practical 
suggestions,  and  they  are  given  with  such  clearness  that 
they  cannot  fail  to  leave  their  impress." 

Obstetrics  for  Nurses.  By  JOSEPH  B.  DfiLEE,  M.  D.,  Professor  of 
Obstetrics  at  the  Northwestern  University  Medical  School,  Chicago. 
i2ino  volume  of  508  pages,  fully  illustrated.  Cloth,  $2.50  net. 

Davis'  Obstetric  &  Gynecologic  Nursing 

NEW  (4th)  EDITION 

The  Trained  Nurse  and  Hospital  Review  says:  "  This  is  one 
of  the  most  practical  and  useful  books  ever  presented  to  the 
nursing  profession."  The  text  is  illustrated. 

Obstetric  and  Gynecologic  Nursing.  By  EDWARD  P.  DAVIS,  M.  D., 
Professor  of  Obstetrics  in  the  Jefferson  Medical  College,  Philadel- 
phia. i-2mo  volume  of  480  pages,  illustrated.  Buckram,  $1.75  net 

Macfarlane's  Gynecology  for  Nurses 

NEW  (2d)  EDITION 

Dr.  A.  M.  Seabrook,  Woman's  Hospital  of  Philadelphia,  says: 
"  It  is  a  most  admirable  little  book,  covering  in  a  concise  but 
attractive  way  the  subject  from  the  nurse's  standpoint." 

A  Reference  Handbook  of  Gynecology  for  Nurses.  By  CATHARINE 
MACFARLANE,  M.  D.,  Gynecologist  to  the  Woman's  Hospital  of  Phila- 
delphia, szmo  of  156  pages,  with  70  illustrations.  Flexible  leather, 
$1.25  net. 

Asher's  Chemistry  and  Toxicology 

Dr.  Asher's  one  aim  was  to  emphasize  throughout  his  book 
the  application  of  chemical  and  toxicologic  knowledge  in  the 
study  and  practice  of  nursing.  He  has  admirably  succeeded. 

i2mo  of  IQO  pages.  By  PHILIP  ASHER,  PH.  G.,  M.  D.,  Dean  and  Pro- 
fessor of  Chemistry,  New  Orleans  College  of  Pharmacy.  Cloth, 
$1.25  net. 


Aikens'  Home  Nurse's  Handbook 

The  point  about  this  work  is  this:  It  tells  you,  and  shows  you 
just  how  to  do  those  little  things  entirely  omitted  from  other 
nursing  books,  or  at  best  only  incidentally  treated.  The 
chapters  on  "Home  Treatments"  and  "Every-Day  Care  of 
the  Baby,"  stand  out  as  particularly  practical. 

Home  Nurse's  Handbook.  By  CHARLOTTE  A.  AIKENS,  formerly  Di- 
rector of  the  Sibley  Memorial  Hospital,  Washington,  D.  C.  i2mo  of 
276  pages,  illustrated.  Cloth.  $1.50  net 

Eye,  Ear,  Nose,  and  Throat  Nursing 

This  book  is  written  from  beginning  to  va&forthe  nurse.  You 
get  antiseptics,  sterilization,  nurse's  duties,  etc.  You  get  an- 
atomy and  physiology,  common  remedies,  how  to  invert  the 
lids,  administer  drops,  solutions,  salves,  anesthetics,  the 
various  diseases  and  their  management.  New  (2d)  Edition. 

Nursing  in  Diseases  of  the  Eye,  Ear,  Nose  and  Throat.  By  the 
Committee  on  Nurses  of  the  Manhattan  Eye,  Ear  and  Throat  Hospital, 
izmo  of  291  pages,  illustrated.  Cloth,  $1.50  net 

Paul's  Materia  Medica  NEw  ^  EDITION 

In  this  work  you  get  definitions — what  an  alkaloid  is,  an  in- 
fusion, a  mixture,  an  ointment,  a  solution,  a  tincture,  etc. 
Then  a  classification  of  drugs  according  to  their  physiologic 
action,  when  to  administer  drugs,  how  to  administer  them, 
and  how  much  to  give. 

A  Text-Book  of  Materia  Medica  for  Nurses.  By  GEORGE  P.  PAUL.M.D., 

Samaritan  Hospital,  Troy,  N.  Y.     i2mo  of  282  pages.     Cloth,  $1.50  net 

Paul's  Fever  Nursing  NEW &>  ED.T.ON 

In  the  first  part  you  get  chapters  on  fever  in  general,  hygiene, 
diet,  methods  for  reducing  the  fever,  complications.  In  the 
second  part  each  infection  is  taken  up  in  detail.  In  the  third 
part  you  get  antitoxins  and  vaccines,  bacteria,  warnings  of 
the  full  dose  of  drugs,  poison  antidotes,  enemata,  etc. 

Nursing  in  the  Acute  Infectious  Fevers.  By  GEORGE  P.  PAUL,  M.  D. 
i2moof  275  pages,  illustrated.  Cloth,  $1.00  net 


McCombs'  Diseases  of  Children  for  Nurses 

NEW  (2d)   EDITION 

Dr.  McCombs'  experience  in  lecturing  to  nurses  has  enabled 
him  to  emphasize//*?/  those  points  that  nurses  most  need  to  know. 
National  Hospital  Record  says:  "We  have  needed  a  good 
book  on  children's  diseases  and  this  volume  admirably  fills 
the  want."  The  nurse's  side  has  been  written  by  head 
nurses,  very  valuable  being  the  work  of  Miss  Jennie  Manly. 

Diseases  of  Children  for  Nurses.  By  ROBERT  S.  McCOMBS,  M.  D.. 
Instructor  of  Nurses  at  the  Children's  Hospital  of  Philadelphia,  izmo 
of  470  pages,  illustrated.  Cloth,  $2.00  net 

Wilson's  Obstetric  Nursing  NEW  (2d)  EDITION 

In  Dr.  Wilson's  work  the  entire  subject  is  covered  from  the 
beginning  of  pregnancy,  its  course,  signs,  labor,  its  actual 
accomplishment,  the  puerperium  and  care  of  the  infant. 
American  Journal  of  Obstetrics  says:  "  Every  page  empasizes 
the  nurse's  relation  to  the  case." 

A  Reference  Handbook  of  Obstetric  Nursing.  By  W.  REYNOLDS 
WILSON.  M.D..  Visiting  Physician  to  the  Philadelphia  Lying-in  Char- 
ity. 32 mo  of  355  pages,  illustrated.  Flexible  leather,  $1.25  net 


NEW  i9th)  EDITION 


American  Pocket  Dictionary 

The  Trained  Nurse  and  Hospital  Review  says:  "We  have 
had  many  occasions  to  refer  to  this  dictionary,  and  in  every 
instance  we  have  found  the  desired  information." 

American  Pocket  Medical  Dictionary.  Edited  by  W.  A.  NEWMAN 
DORLAND,  A.  M.,  M.  D.,  Loyola  University,  Chicago.  Flexible 
leather,  gold  edges,  $1.00  net;  with  patent  thumb  index,  $1.25  net. 


THIRD 
EDITION 


Lewis'  Anatomy  and  Physiology 

Nurses  Joarnal of  Pacific  Coast  says  "it  is  not  in  any  sense 
rudimentary,  but  comprehensive  in  its  treatment  of  the  sub- 
jects.'' The  low  price  makes  this  book  particularly  attractive. 

Anatomy  and  Physiology  for  Nurses.  By  LERov  LEWIS,  M.D..  Lec- 
turer on  Anatomy  and  Physiology  for  Nurses,  Lewis  Hospital,  Bay 
City,  Mich.  i2mo  of  326  pages,  150  illustrations.  Cloth,  $1.75  net 


Bohm  &  Painter's  Massage 

The  methods  described  are  those  employed  in  Hoffa's  Clinic 
— methods  that  give  results.  Every  step  is  illustrated,  showing 
you  the  exact  direction  of  the  strokings.  The  pictures  are 
large.  You  get  the  technic  used  in  Professor  Hoffa's  Clinic. 

Octavo  of  91  pages,  with  97  illustrations.  By  MAX  BOHM,  M.  D., 
Berlin,  Germany.  Edited  by  CHARLES  F.  PAINTER,  M.  D.,  Professor 
or  Orthopedic  Surgery,  Tufts  College  Medical  School,  Boston. 

Cloth,  $1.75  net 


SECOND 
EDITION 


Grafstrom's  Mechano-therapy 

Dr.  Grafstrom  gives  you  here  the  Swedish  system  of  mechan- 
otherapy.  You  are  given  the  effects  of  certain  movements, 
gymnastic  postures,  medical  gymnastics,  general  massage 
treatment,  massage  for  the  various  conditions.  The  illustra- 
tions are  full-page  line  drawings. 

Mechanotherapy  (Massage  and  Medical  Gymnastics).  By  AXEL  V. 
GRAFSTROM,  B.  Sc.,  M.  D.,  Attending  Physician  Gustavus  Adolphus 
Orphanage,  Jamestown,  New  York.  i6mo  of  200  pages. 

Cloth,  $1.25  net 

Friedenwald  and  Ruhrah's  Dietetics  for 


NEW  (3d)   EDITION 

This  work  has  been  prepared  to  meet  the  needs  of  the  nurse, 
both  in  training  school  and  after  graduation.  American  Jour- 
nal of  Nursing  says  it  "is  exactly  the  book  for  which  nurses 
and  others  have  long  and  vainly  sought." 

Dietetics  for  Nurses.  By  JULIUS  FRIEDENWALD,  M.  D.,  Professor  of 
Diseases  of  the  Stomach,  and  JOHN  RUHRAH,  M.D.,  Professor  of 
Diseases  of  Children,  College  of  Physicians  and  Surgeons,  Baltimore. 
i2mo  volume  of  431  pages.  Cloth,  $1.50  net 


FOURTH 
EDITION 


Friedenwald  &  Ruhrah  on  Diet 

This  work  is  a  fuller  treatment  of  the  subject  of  diet,  pre- 
sented along  the  same  lines  as  the  smaller  work.  Everything 
concerning  diets,  their  preparation  and  use,  coloric  values, 
rectal  feeding,  etc.,  is  here  given  in  the  light  of  the  most  re- 
cent researches. 

Diet  in  Health  and  Disease.     By  JULIUS   FRIEDENWALD,    M.D.,  and 
JOHN  RUHRAH,  M.D.    Octavo  volume  of  857  pages.     Cloth,  $4.00  net 


Pyle's  Personal  Hygiene        NEW  <6tn)  EDITION* 

Dr.  Pyle's  work  discusses  the  care  of  the  teeth,  skin,  com- 
plexion and  hair,  bathing,  clothing,  mouth  breathing,  catch- 
ing cold;  singing,  care  of  the  eyes,  school  hygiene,  body 
posture,  ventilation,  heating,,  water  supply,  house-cleaning, 
home  gymnastics,  first-aid  measures,  etc. 

A  Manual  of  Personal  Hygiene.  Edited  by  WALTER  L.  PYLE,  M.  D., 
Wills  Eye  Hospital,  Philadelphia.  i2mo,  543  pages  of  illus.  $1.50  net 

Galbraith's  Personal  Hygiene  and  Physical 
Training  for  Women  ILLUSTRATED 

Dr.  Galbraith's  book  tells  you  how  to  train  the  physical  pow- 
ers to  their  highest  degree  of  efficiency  by  means  of  fresh  air, 
tonic  baths,  proper  food  and  clothing,  gymnastic  and  outdoor 
exercise.  There  are  chapters  on  the  skin,  hair,  development 
of  the  form,  carriage,  dancing,  walking,  running,  swimming, 
rowing,  and  other  outdoor  sports. 

Personal  Hygiene  and  Physical  Training  for  Women.  By  ANNA  M. 
GALBRAITH,  M.D.,  Fellow  New  York  Academy  of  Medicine.  i2mo  of 
371  pages,  illustrated.  Cloth,  $2.00  net 

Galbraith's  Four  Epochs  of  Woman's  Life 

This  book  covers  each  epoch  fully,  in  a  clean,  instructive  way, 
taking  up  puberty,  menstruation,  marriage,  sexual  instinct, 
sterility,  pregnancy,  confinement,  nursing,  the  menopause. 

The  Four  Epochs  of  Woman's  Life.  By  ANNA  M.  GALBRAITH,  M.  D. 
With  an  Introductory  Note  by  JOHN  H.  MUSSER,  M.  D.,  University  of 
Pennsylvania,  12010  of  247  pages.  Cloth,  $1.50  net 

Griffith's  Care  of  the  Baby     NEW  (6.io  EDITION 

Here  is  a  book  that  tells  in  simple,  straightforward  language 
exactly  how  to  care  for  the  baby  in  health  and  disease ;  how 
to  keep  it  well  and  strong;  and  should  it  fall  sick,  how  to 
carry  out  the  physician's  instructions  and  nurse  it  back  to 
health  again. 

The  Care  of  the  Baby.  By  J.  P.  CROZER  GRIFFITH,  M.D.,  Univers- 
ity of  Pennsylvania.  i2mo  of  458  pages,  illustrated.  Cloth,  $1.50  net 


Aikens'  Ethics  for  Nurses  JUST  READY 

This  book  emphasizes  the  importance  of  ethical  training.  It 
is  a  most  excellent  text-book,  particularly  well  adapted  for 
classroom  work.  The  illustrations  and  practical  problems 
used  in  the  book  are  drawn  from  life. 

Studies  in  Ethics  for  Nurses.  By  CHARLOTTE  A.  AIKENS,  formerly 
Superintendent  of  Columbia  Hospital,  Pittsburg.  iamo  of  318  pages. 

Cloth,  $1.75  net. 

Goodnow's  History  of  Nursing  READYSOON 

Miss  Goodnow's  work  gives  the  main  facts  of  nursing -history 
from  the  beginning  to  the  present  time.  It  is  suited  for  class- 
rot  m  work  or  postgraduate  reading.  Sufficient  details  and 
personalities  have  been  added  to  give  color  and  interest,  and 
to  present  a  picture  of  the  times  described. 

History  of  Nursing.  By  MINNIE  GOODNOW,  R.N.,  formerly  Super- 
intendent of  the  Women's  Hospital,  Denver.  i2mo  of  300  pages, 
illustrated. 

Berry's  Orthopedics  for  Nurses        READY 

The  object  of  Dr.  Berry's  book  is  to  supply  the  nurse  with  a 
work  that  discusses  clearly  and  simply  the  diagnosis,  prog- 
nosis and  treatment  of  the  more  common  and  important  ortho- 
pedic deformities.  Many  illustrations  are  included.  The 
work  is  very  practical. 

Orthopedic  Surgery  for  Nurses.  By  JOHN  McWlLLlAMS  BERRY, 
M.D.,  Clinical  Professor  of  Orthopedics  and  Rontgenology,  Albany 
Medical  College.  iamo  of  100  pages,  illustrated.  Cloth,  $1.00  net. 

Whiting's  Bandaging 

This  new  work  takes  up  each  bandage  in  detail,  telling  you — 
and  showing  you  by  original  illustrations — just  how  each 
bandage  should  be  applied,  each  turn  made.  Dr.  Whiting's 
teaching  experience  has  enabled  him  to  devise  means  for  over- 
coming common  errors  in  applying  bandages. 

Bandaging.  By  A.  D.  WHITING,  M.D.,  Instructor  in  Surgery  at  the 
University  of  Pennsylvania.  i2mo  of  151  pages,  with  117  Illustra- 
tions. Cloth,  $1.25  net. 

10 


Hoxie  &  Laptad's  Medicine  for  Nurses 

Medicine  for  Nurses  and  Housemothers.  By  GEORGE 
HOWARD  HOXIE,  M.  D.,  University  of  Kansas;  and 
PEARI,  I/.  LAPTAD.  12mo  of  351  pages,  illustrated. 
Cloth,  $1.50  net.  New  (2d)  Edition. 

This  book  gives  you  information  that  will  help  you  to  carry  out  the 
directions  of  the  physician  and  care  for  the-  sick  in  emergencies.  It 
teaches  you  how  to  recognize  any  signs  and  changes  that  may  occur  be- 
tween visits  of  the  physician,  and,  if  necessary,  to  meet  conditions  until 
the  physician's  arrival. 

Boyd's  State  Registration  for  Nurses 

State  Registration  for  Nurses.  By  LOUIE  CROFT  BOYD, 
R.  N.,  Graduate  Colorado  Training  School  for  Nurses. 
Octovo  of  149  pages.  Cloth,  $1.25  net.  New  (2d)  Edition. 

Morrow's  Immediate  Care  of  Injured 

Immediate  Care  of  the  Injured.    By  ALBERT  S.  MOR- 
ROW, M.  D.,  New  York  City  Home  for  Aged  and  In- 
firm.    Octavo  of  354  pages,  with  242  illustrations. 
Cloth,  $2.50  net.  .   New  (2d)  Edition. 

deNancrede's  Anatomy  NEw  {m  EDITION 

Essentials  of  Anatomy.  By  CHARLES  B.  G.  DENAN- 
CREDE,  M.  D.,  University  of  Michigan.  12mo  of  400 
pages,  180  illustrations.  Cloth,  $1.00  net. 

Morris'  Materia  Medica  NEW  <7«h)  EDITION 

Essentials  of  Materia  Medica,  Therapeutics,  and  Pre- 
scription Writing.     By  HENRY  MORRIS,  M.  D.      Re- . 
vised  by  W.  A.  BASTEDO,  M.  D.,  Columbia  University, 
New  York.     12mo  of  300  pages,  illustrated. 

Cloth,  $1.00  net. 

Register's  Fever  Nursing 

A  Text  Book  on  Practical  Fever  Nursing.  By  EDWARB 
C.  REGISTER,  M.  D.,  North  Carolina  Medical  College. 
Octavo  of  350  pages,  illustrated.  Cloth,  $2.50  net. 

11 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

(LIBRARY 

This  book  is  due  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 
Renewed  books  are  subject  to  immediate  recall. 


8  1961 


C26  J96 


General  Library 


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